Affidavit

AFFIDAVIT OF U.S. CITIZENSHIP

OF

(NAME OF LIMITED LIABILITY COMPANY)

State of )

) ss.:

County of )

I, (Name), of (Physical residence address, city, and state), being duly sworn, depose and say:

1. That I am the (Title of office(s) held) of (Name of Limited Liability Company), a limited liability company organized and existing under the laws of the State of ______ (hereinafter called the “Name of LLC''), with offices at (Business address), in evidence of which formation a certified copy of the Certificate of Formation is filed herewith (or has previously been filed with the Maritime Administration) together with a certified copy of the Limited Liability Company Operating Agreement of (Name of LLC) dated ( Date ). [Evidence of continuing U.S. citizenship status, including amendments to said Certificate and Limited Liability Company Operating Agreement, should be filed at least 45 days prior to the annual documentation renewal date for vessel owners. Other parties required to provide evidence of U.S. citizenship status must file within 30 days after the annual meeting of the stockholders or annually, within 30 days after the original affidavit if there has been no meeting of the stockholders prior to that time.];

2. That I am authorized by and in behalf of (Name of LLC) to execute and deliver this Affidavit of U.S. Citizenship;

3. That (Name of LLC) is a member managed limited liability company with officers and/or directors;

4. That the names of the Chief Executive Officer, by whatever title, the Chairman of the Board of Directors, President, Vice Presidents, Officers, Management Committee members or other individuals who are authorized to act in the absence or disability of such individuals are as follows:¹

Name Title Date and Place of Birth (City/State)

Name Title Date and Place of Birth

(The foregoing list should include the officers, whether or not they are also directors, and all directors, whether or not they are also officers.) Each of said individuals is a Citizen of the United States by virtue of birth in the United States, birth abroad of U.S. citizen parents, by naturalization, or as otherwise authorized by law, except (give name and nationality of all Non-Citizen officers, directors, and members of the Management Committee, if any). The Operating Agreement of (Name of LLC ) provides that (Number) of the (directors or members of the Management Committee) are necessary to constitute a quorum; therefore, the Non-Citizen directors or members of the Management Committee named represent no more than a minority of the number necessary to constitute a quorum.

5.That the information as to Members of (Name of LLC) upon which the (Name of LLC) relies to establish that 75% of the ownership is vested in Citizens of the United States, is as follows: ________________________________________________________________________

Name of Member Date and Place of Birth Type of Member Membership Interest

Total Membership Interest 100%

______________________________ __________________________________________

and that each of said individual Members is a Citizen of the United States by virtue of birth in the United States, birth abroad of U.S. citizen parents, or as otherwise authorized by law, except (give name and nationality for any above identified members who are not U.S. Citizens). Note: Include applicable citizenship information of Members needed to establish 75% interest in U.S. Citizens or attach separate affidavits for such Members.

6. That 75% of the interest in (Name of LLC), as established by the information herein before set forth, is owned by Citizens of the United States; that the title to 75% of the shares of (Name of LLC) is vested in Citizens of the United States free from any trust or fiduciary obligation in favor of any person not a Citizen of the United States; that such proportion of the voting power of (Name of LLC) is vested in Citizens of the United States; that through no contract or understanding is it so arranged that more than 25% the voting power of (Name of LLC) may be exercised, directly or indirectly, in behalf of any person who is not a Citizen of the United States; and that by no means whatsoever, is any interest in (Name of LLC) in excess of 25% conferred upon or permitted to be exercised by any person who is not a Citizen of the United States; and

7. That the affiant has submitted all of the necessary documentation required under 46 C.F.R. ' 356.13 in connection with this Affidavit of U.S. Citizenship for the vessels herein identified.

8. That affiant has carefully examined this affidavit and asserts that all of the statements and representations contained therein are true to the best of his knowledge, information, and belief.

(Name and title of affiant)

.

(Signature of affiant) Date

Penalty for False Statement: A fine or imprisonment, or both, are provided for violation of the proscriptions contained in 18 U.S.C. 1001 (see also, 18 U.S.C. 286, 287 and 46 App. U.S.C. §12122).

1Offices that are currently vacant should be noted when listing Officers and Directors in the Affidavit.

3