CG-5585 (07/12) Application for Vessel Certificate of Financial Responsi

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0046

U.S. Coast Guard
Expires: 12/31/2015
APPLICATION FOR VESSEL CERTIFICATE OF FINANCIAL RESPONSIBILITY
(WATER POLLUTION)
GENERAL
(PART I OF 4 PARTS)

INSTRUCTIONS
Please type or print and submit this application, together with all evidence of financial responsibility required under 33 CFR § 138.80 and all
fees required under 33 CFR § 138.130, to the U.S. Coast Guard, National Pollution Funds Center (Cv) MS7100, 4200 Wilson Boulevard,
Suite 1000, Arlington, VA 20598-7100 (telephone (202) 493-6780, telefax (202) 493-6781). Applicants must answer all applicable questions.
If a question does not apply, answer "not applicable." Incomplete applications will be returned. If additional space is required, supplemental
sheets may be attached. The completed application and all supporting information must be provided in the English language, and must
express all monetary terms in United States Dollars. As an alternative to using this form, you may use the E-COFR system, available
through the NPFC's Web site at https://npfc.uscg.mil/cofr.
1.(a) Legal name of applicant (name of responsible operator of all vessels listed in
Part II):

THIS SPACE FOR USE BY USCG ONLY

(b) English equivalent of legal name if customarily written in language other than
English:

(c) Trade name, if any:

2. Is this the first time the above-named applicant is submitting application Form
CG-5585?

YES

NO

If NO, what Coast Guard control number was assigned to the first application
Form CG-5585?
3. State applicant's legal form of organization, i.e., whether operating as an individual, corporation, partnership, association, joint stock
company, business trust, or other organized group of persons (whether incorporated or not), or as a receiver, trustee, or other liquidating
agent, and briefly describe applicant’s current business activities and length of time engaged therein:

(a) If a corporation, association, or other organization, indicate:
State in the United States, or foreign country, in which incorporated or organized:

Date of incorporation or organization:

(b) If a partnership, provide name and address of each partner:

4. Name and address of applicant's United States agent or other person authorized by applicant to accept service of process and receipt of
notices of designations and presentations of claims in the United States (collectively referred to as "service of process"). (See Part IV).
U.S. applicants may appoint themselves as agent, eliminating the need to complete Part IV.

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 completing this form is 30 minutes. You may submit any comments concerning the accuracy of this burden estimate or any suggestion for
reducing the burden to the: Commandant (NPFC), U.S. Coast Guard, 2100 2nd Street, SW, Washington, DC 20593-0001 or Office of Management and Budget, Paperwork
Reduction Project (1625-0046), Washington, DC 20503.

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EVIDENCE OF FINANCIAL RESPONSIBILITY (PART II OF 4 PARTS)
5. List all vessels that require Certificates of Financial Responsibility under 33 CFR 138.12:
NAME OF VESSEL
(a)

TYPE OF
VESSEL
(See Note 1
below)

(b)

HULL TYPE
(See Note 2
below)

(c)

COUNTRY
OF
REGISTRY
(d)

US VESSELS: Documentation Number
FOREIGN VESSELS: International
Maritime Organization (IMO) Number
(e)

GROSS
TONS(f)

NOTE 1: Please designate the Type of Vessel in column 5(b) by using a number from one of the following categories:
CARGO VESSELS, SELF-PROPELLED
Breakbulk freighter =10
Containership * = 11
Roll on-roll off = 12
Barge carrier (e.g., lash, seabee) = 13
Combination breakbulk containership * = 14
Combination roll on-roll off containership * = 15
Combination barge carrier containership * =16
Tanker = 17
Dry bulk carrier = 18
All other self-propelled cargo vessels = 19
Oil/bulk/ore carrier (OBO) = 20

PASSENGER VESSELS
Passenger vessel** = 30
Combination passenger/cargo vessel** = 31
Ferry** = 32
RECREATIONAL VESSELS
All types of pleasure craft = 40

UTILITY CRAFT
Tank barge = 50
Tug and towboat = 51
Barge and scow = 52
Drilling rig = 53
Fishing vessel = 54
Factory vessel = 55
Research vessel = 56
All other utility craft*** = 57
MISCELLANEOUS
Vessels not otherwise
specified = 60

* Containership categories should be assigned only to vessels having fixed container cells or regularly carrying multi-tier container
deckloads.
** Passenger categories should be assigned only to vessels carrying more than 12 passengers for hire.
*** Includes floating cranes, dredges, docks, etc.
NOTE 2: For Vessel Types 17 (Tanker), 20 (Oil/bulk/ore carrier), 50 (Tank Barge), or 53 (Drilling Rig), please designate the Hull Type as
defined in 33 CFR 138.220, in column 5(c), by using a letter from one of the following categories:
S = SINGLE HULL, including a single hull vessel fitted with double sides only or a double bottom only
D = DOUBLE HULL
5. (g) Provide owner information for each vessel below. Enter “SAME” in the OWNER column if the owner is the same as the operator:
NAME OF VESSEL

CG-5585 (07/12)

OWNER

OWNER'S MAILING ADDRESS

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PART II (CONT’D)
6. Items 7 through 11 are methods of establishing and maintaining evidence of financial responsibility. Answer only the item(s) which are
applicable to this application:
Insurance
(Answer item 7)

Surety Bond
(Answer item 8)

Financial Guaranty
(Answer item 9)

Self-Insurance
(Answer item 10)

Other Services
(Answer item 11)

7. Name and address of applicant's insurance guarantor (Insurance Guaranty Form CG-5586 or Master Insurance Guaranty Form CG5586-1 must be filed before a Certificate will be issued):

8. Total amount of surety bond guaranty:

$
Name and address of applicant's surety bond guarantor (Surety Bond Guaranty Form CG-5586-2 must be filed before a Certificate will
be issued):

9. Name and address of applicant's financial guarantor (Financial Guaranty Form CG-5585-3, or Master Financial Guaranty
Form CG-5586-4 and all financial data and other information required by 33 CFR 138.80(b)(4) must be filed before a
Certificate will be issued):

Financial Guarantor's fiscal year:
____________________ to
(Month)
(Day)

____________________
(Month)
(Day)

10. If applicant intends to qualify as a self-insurer attach all financial data and other information required by 33 CFR 138.80(b)(3) and
indicate fiscal year. (All required information must be filed before a Certificate will be issued):
____________________ to
(Month)
(Day)

____________________
(Month)
(Day)

11. If applicant intends to qualify through other evidence, supply all information required by 33 CFR 138.80(b)(5):

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DECLARATION (PART III OF 4 PARTS)
12. Applicant's mailing address (street, number, post office box,
city, state or country. Indicate ZIP code if in the United States):

14. Type or print in this space the name and title of the official who
is signing the application:

15. Address of principal office in the United States (if any):

13. Telefax number :

16. Telephone no. (area code and number):

17. E-mail address :

I declare that I have examined this application, including any accompanying schedules and statements, and, to the best of my knowledge
and belief, it is true, correct, and complete. Furthermore, the applicant named in item 1(a) of Part I above is the responsible operator of all
vessels now listed in or later added to this application. I agree that in the event the agent designated in item 4 of Part I above, or that
agent's replacement as may be designated later with the approval of the Director, U.S. Coast Guard National Pollution Funds Center,
cannot be served due to death, disability, unavailability, or similar event, the Director, U.S. Coast Guard National Pollution Funds Center,
is considered the agent for service of process. I have signed this application in my capacity as an authorized official of the applicant, or, if
acting under a power of attorney, pursuant to the power vested in me by the applicant as evidenced by the attached power of attorney.

IMPORTANT

DATE:

SIGNATURE OF AUTHORIZED OFFICIAL:

NOTE Please be sure that Parts I, II, and III have been completed in full and that Part III has been dated and signed. Then proceed to
Part IV, attached.
NO CERTIFICATE WILL BE ISSUED UNLESS A COMPLETED APPLICATION FORM HAS BEEN RECEIVED, PROCESSED AND
APPROVED.
COMMENTS:

Any person who knowingly and willfully makes a false statement in this application is subject to the sanctions prescribed in
18 U.S.C. 1001
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CONCURRENCE OF AGENT (PART IV OF 4 PARTS)
PART IV-A must be completed by the person designated in item 4 of Part I to serve as applicant's United States agent for
service of process.
Part IV-B must be completed by the applicant. After Parts IV-A and IV-B are completed, Part IV should be submitted to the
Director, Coast Guard National Pollution Funds Center, by the applicant or by the agent, either separately or together with
Parts I, II, and III. (Part IV need not be completed if the agent designated in item IV of Part I already has submitted to the
U.S. Coast Guard an acceptable blanket Concurrence of Agent, agreeing to serve on behalf of certain applicants who
designate that agent. Part IV also need not be completed if the applicant is a United States entity and has appointed itself
as agent in item 4 of Part I.)

PART IV-A
It is hereby agreed that ________________________________________________________________________________
shall serve as the applicant's United States agent for service of process for purposes of 33 CFR part 138. This designation and
agreement shall cease immediately in the event the applicant designates a new agent acceptable to the Director, National Pollution
Funds Center.
Date:
Signature of person signing on behalf of agent:
Title:
Business address:

PART IV-B (TO BE COMPLETED BY APPLICANT)
Name of applicant (from item 1(a)):
Signature of authorized official signing on behalf of applicant: ________________________________________________________
(Person signing here should also sign in
appropriate place on Part III)
Date:
Type or Print Name and Title: _________________________________________________________________________________
PRIVACY ACT NOTICE
Purpose: The Coast Guard will use this information as evidence that the owners and operators, including demise charterers, of certain vessels have
established and are maintaining evidence of financial responsibility (i.e., ability to pay) sufficient to meet the maximum amount of liability to which they
could be subjected under the Oil Pollution Act of 1990 (33 U.S.C. 2702(a); 33 U.S.C. 2704) (OPA'90), and the Comprehensive Environmental
Response, Compensation and Liability Act of 1980, as amended (42 U.S.C. 9607) (CERCLA), in the event of a discharge, or substantial threat of
discharge, of oil or a release, or threatened release, of hazardous substances, into the navigable waters, adjoining shorelines or the exclusive
economic zone of the United States.
Routine Uses: This information will be used by and disclosed to Coast Guard personnel and contractors or other agents who need the information to
assist in activities related to the OPA'90 and CERCLA evidence of financial responsibility requirements, including personnel responsible for the storage
and ultimate disposal of the information. Additionally, the Coast Guard may share the information with facility operators, law enforcement or other
government agencies as necessary to respond to actual or threatened discharges of oil or releases of hazardous substances, or pursuant to its
published Privacy Act system of records notice.
Disclosure: Furnishing this information (including your SSN) is voluntary; however, if the requested information is not furnished, the Coast Guard will
be unable to certify compliance by vessel owners and operators, including demise charterers, with the applicable OPA'90 and CERCLA evidence of
financial responsibility requirements. This may result in the withholding or revocation of vessel clearance and other sanctions as specified OPA'90, 33
U.S.C. 2716(b) and 42 U.S.C. 9608(a).
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