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

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
BOAT OWNER'S REPORT - POSSIBLE SAFETY DEFECT

OMB No. 1625-0071
Exp. 03/31/2016

OWNER INFORMATION
Last Name

First Name & Middle Initial

Street Address

Work Phone Number

City

State

Home Phone Number
ZipCode

BOAT AND ENGINE INFORMATION
Model Year

Boat Manufacturer

Model Name

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

Recreational Use

Model Year

Engine and Drive Manufacturer
Gas

Diesel

Inboard

Commercial Use

Outboard

SternDrive

Jet

Other* *

Model Name or No.
Sail

Manual

Other* *

APPLICABLE ACCIDENT INFORMATION
Accident

Yes

Name(s) of Deceased

No

No. Injuries

No. Fatalities

Estimated Property Damage

Age(s) of Deceased

Accident Date and Location

Description of Accident

Privacy Act Statement
a. Authority:  5 U.S.C. 301; 14 U.S.C. 93; the Federal Records Act; 46 U.S.C. 4310; and 33 C.F.R. 179.
b.  Purpose:  Subparagraph 4310(f) of Title 46, United States Code gives the Coast Guard the authority to require manufacturers of recreational boats and
items of "designated associated equipment" to notify owners and replace or repair boats and items of designated associated equipment which fail to comply
with applicable Federal safety standards or are found to contain defects related to safety discovered in their products.  For the purposes of 46 U.S.C. 4310,
the phrase, "designated associated equipment," includes inboard engines, outboard motors and sterndrive units.
c. Routine Uses: 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.
d. Disclosure:  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-BSX-23), U.S. Coast Guard, Washington, DC
20593-0001 or Office of Management and Budget, Paperwork Reduction Project (1625-0071), Washington, DC 20503.

CG-5578 (08/15)

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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-BSX-23)
US Coast Guard Headquarters Stop 7501
Recreational Boating Product Assurance Branch
2703 Martin Luther King JR Ave, SE
Washington, DC 20593-7501

CG-5578 (08/15)

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