CG-5578 Boat Owner's Report - Possible Safety Defect

DEPARTMENT OF
HOMELAND SECURITY BOAT OWNER'S REPORT - POSSIBLE SAFETY DEFECT
U.S. COAST GUARD
U.S. Coast Guard Boating Safety Division
CG-5578 (6/94)
OWNER INFORMATION
FIRST NAME & MIDDLE INITIAL

LAST NAME

STREET ADDRESS

TELEPHONE NO. (W/AREA CODE)
Work:
Home:
STATE
ZIPCODE

CITY

BOAT AND ENGINE INFORMATION
MODEL YEAR
MODEL NAME

BOAT MANUFACTURER

OMB NO. 1625-0071
(Expires 1/31/2013)

HULL IDENTIFICATION NUMBER*

*Twelve character manufacturer serial number on outboard starboard side of transom also shown on State registration certificate

BOAT LENGTH

BOAT TYPE ( Ex. bowrider, cuddy cabin, runabout, personal watercraft, etc.)

DATE PURCHASED

DEALER'S NAME AND ADDRESS

NEW

USED

ENGINE AND DRIVE MANUFACTURER

GAS

DIESEL

INBOARD

OUTBOARD

RECREATIONAL USE

COMMERCIAL USE

MODEL YEAR

MODEL NAME OR NO.

I/O

JET

SAIL

MANUAL

OTHER*

*
APPLICABLE ACCIDENT INFORMATION
NO. INJURIES
NO. FATALITIES
ESTIMATED PROPERTY DAMAGE ($)

ACCIDENT
YES

NO

NAME(S) OF DECEASED

AGE(S) OF DECEASED

ACCIDENT DATE & LOCATION

DESCRIPTION OF ACCIDENT

Privacy Act Statement
(The Privacy Act of 1974, Public Law 93-579)
This information is requested pursuant to authority in 46 U.S.C. 4310(f) (formerly the Federal Boat Safety Act of 1971). You are under no obligation
to respond to this questionnaire. Your response may be used to assist the Coast Guard in determining whether a manufacturer should take appropriate
action to correct a safety defect. If the Coast Guard proceeds with administrative enforcement or litigation against a manufacturer, your response, or
a summary thereof, may be used in support of the Coast Guard's action.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control
number.The Coast Guard estimates that the average burden for this report form is 24 minutes. You may submit any comments concerning the accuracy
of this burden estimate or any suggestions for reducing the burden to: Commandant (CG-54223), U.S. Coast Guard, Washington, DC 20593-0001 or
Office of Management and Budget, Paperwork Reduction Project (1625-0071), Washington, DC 20503.

Reverse of CG-5578 (6-94)
Description of possible safety defect. Attach copies of any correspondence, repair orders, invoices, marine
surveys, photos or sketches that you feel could substantiate the existence of the safety defect. If the possible safety
defect is in a component installed or modified by someone other than the boat manufacturer, please so indicate and
give details.
Defect description:

Signature of owner:

Date:

Fold to show return address below. Fasten with tape and mail.

COMMANDANT (CG-54223)
RECREATIONAL BOATING PRODUCT
ASSURANCE BRANCH
U.S. COAST GUARD HEADQUARTERS
2100 SECOND STREET SW
WASHINGTON DC 20593-0001