CG-1280 Vessel Renewal Notification Application for Renewal

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
VESSEL RENEWAL NOTIFICATION
APPLICATION FOR RENEWAL
RETURN TO:

OMB Approved: 1625-0027
Expiration Date: 04/30/2013

NATIONAL VESSEL DOCUMENTATION CENTER
PO BOX 1119
FALLING WATERS, WV 25419-1119

NOTICE:
THE CERTIFICATE OF DOCUMENTATION FOR THE VESSEL IDENTIFIED BELOW EXPIRES ON THE DATE INDICATED. COMPLETE THE
CERTIFICATION ON THIS FORM AND RETURN IT PRIOR TO THE DATE OF EXPIRATION BY MAIL, FAX OR EMAIL (PDF) USING THE INFORMATION
PROVIDED BELOW.
IF UNABLE TO COMPLETE THE CERTIFICATION BECAUSE ONE OR MORE OF THE ITEMS LISTED HAS CHANGED, CONTACT THE NATIONAL
VESSEL DOCUMENTATION CENTER. FAILURE TO REPORT CHANGES OR RETURN THIS CERTIFICATION BY THE EXPIRATION DATE MAY
RESULT IN PENALTIES AND/OR REMOVAL OF THE VESSEL FROM DOCUMENTATION. OPERATION OF THE VESSEL WITH AN INACCURATE OR
INVALID CERTIFICATE OF DOCUMENTATION MAY RESULT IN ADDITIONAL PENALTIES. IF SUBMITTED AFTER EXPIRATION DATE, INCLUDE
$5.00 LATE FEE, ACCEPTED FOR UP TO 30 DAYS PAST EXPIRATION.
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 FORM IS 5 MINUTES. YOU MAY SUBMIT ANY COMMENTS
CONCERNING THE ACCURACY OF THIS BURDEN ESTIMATE OR ANY SUGGESTIONS FOR REDUCING THE BURDEN TO: U.S. COAST
GUARD, NATIONAL VESSEL DOCUMENTATION CENTER, 792 T J JACKSON DRIVE, FALLING WATERS, WEST VIRGINIA 25419 OR OFFICE
OF MANAGEMENT AND BUDGET, PAPERWORK REDUCTION PROJECT (1625-0027), WASHINGTON, DC 20593.

PHONE: (800) 799-8362 OR (304) 271-2400
FAX:
(304) 271-2541
EMAIL: [email protected]
PHYSICAL LOCATION: 792 T J JACKSON DRIVE, FALLING WATERS, WV 25419
POTENTIAL PENALTIES FOR FALSE STATEMENTS OR REPRESENTATION BY OWNER OR REPRESENTATIVE:
VESSEL FORFEITURE (46 USC 12151) AND FINE AND/OR IMPRISONMENT (18 USC 1001)

PLEASE INDICATE ADDRESS CHANGE BELOW. (A PHYSICAL ADDRESS IS REQUIRED WHEN USING A POST OFFICE BOX.)

NAME

E-MAIL ADDRESS

PHYSICAL ADDRESS

P.O. BOX

CITY, STATE, ZIP

CITY, STATE, ZIP

I CERTIFY THAT THE RECITATIONS CONCERNING THE VESSEL: NAME, TONNAGE, DIMENSIONS, PROPULSION, OWNERSHIP, HAILING PORT,
RESTRICTIONS, ENTITLEMENTS, REMARKS AND ENDORSEMENTS CONTAINED IN THE CERTIFICATE OF DOCUMENTATION REMAIN
ABSOLUTELY THE SAME.

AUTHORIZED SIGNATURE
CAPACITY OF PERSON SIGNING (OWNER/AGENT)
CG-1280 (04/12)

DATE
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