CG-1258 Application for Initial, Exchange, or Replacement of Cer

DEPARTMENT OF HOMELAND SECURITY

OMB No: 1625-0027

U.S. Coast Guard
APPLICATION FOR INITIAL, EXCHANGE, OR REPLACEMENT OF
CERTIFICATE OF DOCUMENTATION; REDOCUMENTATION

Expires: 06/30/2016

NOTE: FILING THIS APPLICATION DOES NOT ENTITLE A VESSEL TO DOCUMENTATION OR TO ANY CHANGES SOUGHT ON A CERTIFICATE OF
DOCUMENTATION. OFFICIAL NUMBERS DESIGNATED ON THE BASIS OF THIS APPLICATION ARE NOT TRANSFERABLE. ONLY A CURRENT
CERTIFICATE OF DOCUMENTATION IS VALID FOR VESSEL OPERATION.

COMPLETE FOR ALL APPLICATIONS
A. VESSEL NAME (REQUIRED)

B. OFFICIAL # (IF AWARDED)

CLICK ICON TO ATTACH LIST OF ADDITIONAL VESSEL(S)
C. HULL ID # (IF ANY)

D. IMO # (IF ANY)

E. HAILING PORT INCLUDING STATE (TO BE MARKED ON VESSEL)

SOCIAL SECURITY OR TAX ID NUMBER (REQUIRED – 46 USC 12104):

F. NAME OF MANAGING OWNER

SSN:
E-MAIL ADDRESS:
TELEPHONE NUMBER:
G. PHYSICAL ADDRESS OF MANAGING OWNER (REQUIRED –
46 CFR 67.113)

TIN:

MAILING ADDRESS OF MANAGING OWNER (IF DIFFERENT THAN
PHYSICAL ADDRESS – E.G., P.O. BOX)

SOCIAL SECURITY OR TAX ID NUMBER(S) OF OTHER OWNER(S)
SSN:
TIN:

H. NAME(S) OF OTHER OWNER(S)

CLICK ICON TO ATTACH LIST OF ADDITIONAL OWNER(S)
I. PURPOSE OF APPLICATION
1. EXCHANGE OF CERTIFICATE OF DOCUMENTATION.
2. REPLACEMENT OF LOST, WRONGFULLY WITHHELD OR MUTILATED CERTIFICATE OF DOCUMENTATION.
3. RE-INSTATEMENT OF CERTIFICATE OF DOCUMENTATION FOLLOWING FAILURE TO RENEW.
4. RETURN TO DOCUMENTATION FOLLOWING DELETION. VESSEL NAME WHEN LAST DOCUMENTED:_____________________________
5. APPLICATION FOR OFFICIAL NUMBER AND FIRST CERTIFICATE OF DOCUMENTATION. VESSEL
WAS BUILT AT ____________________________________________________________ IN ____________________________
OR
CITY, STATE, COUNTRY
MONTH/YEAR
IS UNDER CONSTRUCTION AT __________________________________ AND IS SCHEDULED FOR COMPLETION IN___________
HULL MATERIAL:

WOOD

STEEL

FIBROUS REINFORCED PLASTIC

ALUMINUM

CONCRETE

OTHER (DESCRIBE) _______________________________APPROXIMATE LENGTH OF VESSEL_______________
PREVIOUS NAMES, NUMBERS, OR FOREIGN REGISTRATIONS OF VESSEL __________________________________________________
J. ENDORSEMENTS FOR WHICH APPLICATION IS MADE
RECREATIONAL

COASTWISE – BOWATERS ONLY (CERTIFICATE ON FILE)

FISHERY

COASTWISE – OIL SPILL RESPONSE ONLY (LETTER OF QUALIFICATION ON FILE)

COASTWISE

COASTWISE UNDER CHARTER TO AN ENTITY QUALIFIED TO ENGAGE IN COASTWISE TRADE

REGISTRY

(COPY OF CHARTER ON FILE)

K. PRIMARY SERVICE & HORSEPOWER
HORSEPOWER:__________________

OFFSHORE SUPPLY VESSEL

RECREATIONAL

COMMERCIAL FISHING BOAT

PASSENGER (6 OR FEWER)

RESEARCH VESSEL

FISH PROCESSING VESSEL

PASSENGER (MORE THAN 6 )

SCHOOL SHIP

FREIGHT SHIP

PASSENGER BARGE (6 OR FEWER)

TANK BARGE

FREIGHT BARGE

PASSENGER BARGE (MORE THAN 6)

TANK SHIP

INDUSTRIAL VESSEL

PUBLIC FREIGHT

TOWING VESSEL

MOBILE OFFSHORE DRILLING UNIT

PUBLIC TANKSHIP/BARGE

UNCLASSIFIED VESSEL

OIL RECOVERY

PUBLIC VESSEL, UNC

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L.

CITIZENSHIP OF OWNER (CHECK THE BOX(ES) TO SHOW THE TYPE(S) OF ENTITY(IES) THAT OWNS THE VESSEL)
ONE OR MORE INDIVIDUALS
I (WE) CERTIFY THAT ALL OWNERS OF THIS VESSEL ARE CITIZENS OF THE UNITED STATES
GOVERNMENT ENTITY (FEDERAL, STATE, TERRITORY, POSSESSION OR SUBDIVISION)
CORPORATION (SEE SECTION M, ITEM 4 WHEN APPLYING FOR A FISHERY OR COASTWISE ENDORSEMENT).
1.

STATE OF INCORPORATION_____________________________

2

CITIZENSHIP OF CHIEF EXECUTIVE OFFICER BY WHATEVER TITLE___________________________

3.

CITIZENSHIP OF CHAIRMAN OF THE BOARD__________________________

4.

NUMBER OF DIRECTORS NECESSARY TO CONSTITUTE A QUORUM_____________________________

5.

NUMBER OF ALIEN DIRECTORS______________________

6.

PERCENTAGE OF STOCK OWNED BY U.S. CITIZENS ELIGIBLE TO DOCUMENT VESSELS IN THEIR OWN RIGHT, WITH THE
ENDORSEMENT(S) SOUGHT ON THIS APPLICATION IN ACCORDANCE WITH 46 CFR PART 67 (SUBPART C)
LESS THAN 50%
50% OR MORE: STATE EXACT
PERCENTAGE _____________

75% OR MORE (AND, AT EACH TIER, IF APPLICABLE)
75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE)

LIMITED LIABILITY COMPANY (LLC): (COMPLETE EQUITY SECTION AND CHOOSE TYPE) (SEE SECTION M, ITEM 5 WHEN APPLYING
FOR A FISHERY OR COASTWISE ENDORSEMENT).
EQUITY INTEREST OWNED BY PERSONS ELIGIBLE TO DOCUMENT VESSELS IN THEIR OWN RIGHT WITH THE ENDORSEMENT SOUGHT IN
ACCORDANCE WITH 46 CFR PART 67 (SUBPART C)
LESS THAN 50%
50% OR MORE: STATE EXACT
PERCENTAGE _____________
1.

75% OR MORE (AND, AT EACH TIER, IF APPLICABLE)
75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE)

MEMBER MANAGED LIMITED LIABILITY COMPANY
I (WE) CERTIFY THAT ALL MEMBERS OF THIS LLC ARE CITIZENS OF THE UNITED STATES ELIGIBLE TO DOCUMENT VESSELS WITH
THE ENDORSEMENT(S) SOUGHT IN THEIR OWN RIGHT.
(CLICK ICON TO ATTACH LIST OF ALL MEMBERS)(REQUIRED)

OR
2.

LIMITED LIABILITY COMPANY NOT MANAGED BY MEMBERS AND NOT SIMILAR TO GENERAL PARTNERSHIP:
PLEASE NOTE (A) & (B) MUST BE CHECKED FOR FISHERY AND COASTWISE ENDORSEMENTS; NOT REQUIRED FOR COASTWISE
OIL SPILL OR COASTWISE UNDER CHARTER ENDORSEMENTS.
A.

I (WE) CERTIFY THAT ANY PERSON ELECTED TO MANAGE THE LLC OR WHO IS AUTHORIZED TO BIND THE LLC, AND ANY
PERSON WHO HOLDS A POSITION EQUIVALENT TO THE CHIEF EXECUTIVE OFFICER, BY WHATEVER TITLE, AND THE
CHAIRMAN OF THE BOARD OF DIRECTORS IN A CORPORATION, AND ANY PERSONS AUTHORIZED TO ACT IN THEIR ABSENCE
ARE CITIZENS OF THE UNITED STATES.
B. NON-CITIZENS DO NOT HAVE AUTHORITY WITHIN A MANAGEMENT GROUP, WHETHER THROUGH VETO POWER, COMBINED
VOTING, OR OTHERWISE, TO EXERCISE CONTROL OVER THE LLC.
STATE WHERE ORGANIZED__________________________________
PARTNERSHIP (COMPLETE EQUITY SECTION AND CHOOSE TYPE) (SEE SECTION M, ITEM 5 WHEN APPLYING FOR FISHERY OR
COASTWISE ENDORSEMENT)
EQUITY INTEREST OWNED BY PERSONS ELIGIBLE TO DOCUMENT VESSELS IN THEIR OWN RIGHT WITH THE ENDORSEMENT SOUGHT IN
ACCORDANCE WITH 46 CFR PART 67 (SUBPART C)
LESS THAN 50%
50% OR MORE STATE EXACT
PERCENTAGE _____________
1.

2.

75% OR MORE (AND, AT EACH TIER, IF APPLICABLE)
75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE)

GENERAL PARTNERSHIP
I (WE) CERTIFY THAT ALL PARTNERS IN THIS PARTNERSHIP ARE CITIZENS OF THE UNITED STATES ELIGIBLE TO DOCUMENT
VESSELS WITH THE ENDORSEMENT(S) SOUGHT IN THEIR OWN RIGHT.
LIMITED PARTNERSHIP
I (WE) CERTIFY THAT ALL GENERAL PARTNERS IN THIS PARTNERSHIP ARE CITIZENS OF THE UNITED STATES, ELIGIBLE TO
DOCUMENT VESSELS WITH THE ENDORSEMENT(S) SOUGHT IN THEIR OWN RIGHT.

(CLICK ICON TO ATTACH LIST OF ALL GENERAL PARTNERS)(REQUIRED)
CORPORATION QUALIFIED AND APPLYING UNDER 46 CFR 68.01 (BOWATERS)
I (WE) CERTIFY THAT THE CORPORATE STRUCTURE HAS NOT CHANGED SINCE ISSUANCE OF THE CERTIFICATE OF COMPLIANCE.
VESSEL OWNED OR OPERATED BY NOT-FOR-PROFIT OIL RECOVERY COOPERATIVE
I (WE) CERTIFY THAT THE INFORMATION ON FILE WITH REGARD TO COOPERATIVE AND ISSUANCE OF THE LETTER OF
QUALIFICATION REMAINS UNCHANGED.
JOINT VENTURE OR ASSOCIATION
I (WE) CERTIFY THAT ALL MEMBERS OF THIS (JOINT VENTURE) (ASSOCIATION) ARE CITIZENS OF THE UNITED STATES, ELIGIBLE TO
DOCUMENT VESSELS IN THEIR OWN RIGHT WITH THE ENDORSEMENT(S) SOUGHT.
(CLICK ICON TO ATTACH LIST OF ALL JOINT VENTURERS/MEMBERS)(REQUIRED)
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TRUST ARRANGEMENT (COMPLETE EQUITY/STOCK SECTION) (SEE SECTION M, ITEM 5 WHEN APPLYING FOR A FISHERY OR COASTWISE
ENDORSEMENT)
I (WE) CERTIFY THAT ALL TRUSTEES AND ALL BENEFICIARIES WITH AN ENFORCEABLE INTEREST IN THIS TRUST ARRANGEMENT
ARE CITIZENS OF THE UNITED STATES, ELIGIBLE TO DOCUMENT VESSELS WITH THE ENDORSEMENT(S) SOUGHT IN THEIR OWN
RIGHT.
EQUITY INTEREST OWNED BY PERSONS ELIGIBLE TO DOCUMENT VESSELS IN THEIR OWN RIGHT WITH THE ENDORSEMENT(S) SOUGHT IN
ACCORDANCE WITH 46 CFR PART 67 (SUBPART C)
LESS THAN 50%
50% OR MORE: STATE EXACT
PERCENTAGE _____________

75% OR MORE (AND, AT EACH TIER, IF APPLICABLE)
75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE)

OR
VESSEL OWNED IN A TRUST ARRANGEMENT PURSUANT TO 46 USC 12111(c) (CROSS BORDER FINANCING)
I (WE) CERTIFY THAT THE VESSEL IS OWNED IN A TRUST ARRANGEMENT THAT QUALIFIES FOR A REGISTRY ENDORSEMENT
ONLY PURSUANT TO PUBLIC LAW 104-324, SECT. 1136. ATTACHED IS AN AFFIDAVIT OF EACH TRUSTEE AND CITIZENSHIP
EVIDENCE FOR THE CHARTERER AS REQUIRED UNDER THE STATUTE.

M.

(CLICK ICON TO ATTACH LIST OF ALL TRUSTEES AND ALL BENEFICIARIES WITH AN ENFORCEABLE INTEREST)(REQUIRED)
I (WE) CERTIFY THAT: (MARK ALL THAT ARE APPLICABLE. ITEM 5. NOT REQUIRED FOR COASTWISE BOWATER ONLY, OIL SPILL, OR
UNDER CHARTER ENDORSEMENTS.)
1.

I AM (WE ARE) A CITIZEN(S) OF THE UNITED STATES AND LEGALLY AUTHORIZED TO EXECUTE THIS APPLICATION IN THE
CAPACITY SHOWN;

2.

IN ACCORDANCE WITH 46 CFR PART 67 (SUBPART I) THE VESSEL(S) TO WHICH THIS APPLICATION APPLIES;
(a)
HAS (HAVE) BEEN MARKED OR
WILL BE MARKED;
(b) WILL AT ALL TIMES REMAIN UNDER THE COMMAND OF A U.S. CITIZEN, UNLESS DOCUMENTED SOLELY WITH A
RECREATIONAL ENDORSEMENT; WILL NOT BE OPERATED IN A TRADE NOT AUTHORIZED BY THE ENDORSEMENT(S) ON THE
CERTIFICATE(S) OF DOCUMENTATION. THE NAME(S) OF THE VESSEL(S) WILL NOT BE CHANGED WITHOUT APPROVAL FROM
THE NATIONAL VESSEL DOCUMENTATION CENTER; AND I(WE) WILL PROMPTLY NOTIFY THE NATIONAL VESSEL
DOCUMENTATION CENTER UPON A CHANGE IN ANY OF THE INFORMATION OR REPRESENTATIONS IN THIS APPLICATION.

3.
4.

HAS (HAVE) NOT OR

HAS (HAVE) BEEN REBUILT OR SUBSTANTIALLY ALTERED SINCE LAST DOCUMENTATION;

THE VESSEL IS
NOT TITLED UNDER A STATE OR
TITLED UNDER THE LAWS OF_________________________________

THE FOLLOWING ITEM IS REQUIRED FOR COASTWISE AND/OR FISHERY ENDORSEMENTS; HOWEVER, IT IS NOT REQUIRED FOR COASTWISE
BOWATER ONLY, OIL SPILL, OR UNDER CHARTER ENDORSEMENTS.
5.

U.S. CONTROL CERTIFICATION: THERE IS NO CONTRACT OR UNDERSTANDING THAT PROVIDES MORE THAN 25% OF THE
VOTING POWER IN THE PARTNERSHIP, LIMITED LIABILITY COMPANY, CORPORATION, OR OTHER OWNING ENTITY EITHER
DIRECTLY OR INDIRECTLY ON BEHALF OF ANY PERSON NOT A CITIZEN OF THE UNITED STATES. BY NO MEANS
WHATSOEVER IS CONTROL IN EXCESS OF 25% CONFERRED UPON OR PERMITTED TO BE EXERCISED BY A PERSON WHO IS
NOT A CITIZEN OF THE UNITED STATES.

POTENTIAL PENALTIES FOR FALSE STATEMENTS OR REPRESENTATIONS BY OWNER OR REPRESENTATIVE: CIVIL, MONETARY, VESSEL
FORFEITURE (46 USC 12151), FINE AND/OR IMPRISONMENT (18 USC 1001)
_____________________________________________
SIGNATURE

____________________________
DATE

_________________________________________
CAPACITY (E.G., OWNER, AGENT, TRUSTEE,
GENERAL PARTNER, CORPORATE OFFICER, MEMBER)

______________________________________________________________
PRINTED OR TYPED NAME

APPLICATION FEES ARE NOT REFUNDABLE (46 CFR 67.500 (e)).
PRIVACY ACT STATEMENT
IN ACCORDANCE WITH 5 U.S.C. 553a, THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL INFORMATION TO THE U.S. COAST
GUARD.
1. AUTHORITY. SOLICITATION OF THIS INFORMATION IS AUTHORIZED BY 46 U.S.C., CHAPTERS 121 AND 125; 46 U.S.C. APP. 802 AND 883.
2. THE PRINCIPAL PURPOSES FOR WHICH THIS INFORMATION IS TO BE USED ARE:
(1) TO DETERMINE CITIZENSHIP OF THE OWNER OF THE VESSEL FOR WHICH APPLICATION FOR DOCUMENTATION IS MADE; AND
(2) TO DETERMINE ELIGIBILITY OF THE VESSEL TO BE DOCUMENTED WITH THE TRADE ENDORSEMENT SOUGHT.
3. THE ROUTINE USES WHICH MAY BE MADE OF THIS INFORMATION INCLUDE RELEASE TO LAW ENFORCEMENT OFFICIALS, TO THE GENERAL PUBLIC UNDER
FREEDOM OF INFORMATION ACT, AND TO PUBLISH INFORMATION ABOUT U.S. DOCUMENTED VESSELS.
4. DISCLOSURE OF THE INFORMATION REQUESTED ON THIS FORM IS VOLUNTARY, HOWEVER, FAILURE TO PROVIDE THE INFORMATION REQUESTED WILL
RESULT IN DENIAL OF THE APPLICATION FOR DOCUMENTATION, WHICH MAY PREVENT THE OWNER FROM OPERATING THE VESSEL(S) IN A SPECIFIED
TRADE.
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 30 MINUTES. YOU MAY SUBMIT ANY COMMENTS CONCERNING THE ACCURACY
OF THIS BURDEN ESTIMATE OR MAKE 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 20503.

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INSTRUCTIONS FOR COMPLETING FORM CG-1258
A. VESSEL NAME: Insert name by which you wish the vessel to be known. If applying to change the vessel's name, insert the old vessel name in
parenthesis. Only standard Alpha and Numeric Characters in the vessel name will appear on the Certificate of Documentation. Click icon for
attachment if application covers multiple vessels.
B. OFFICIAL NUMBER: Insert the Official Number (O/N) awarded by the Coast Guard for all but Initial Issue cases.
C. HULL ID #: Insert Hull Identification Number (HIN) as assigned in accordance with 33 CFR 81.
D. IMO #: Insert International Maritime Organization Number (IMO), if any.
E. HAILING PORT: Insert name of place and state exactly as it is or will be marked on the vessel. The hailing port must be a place in the United
States. Commonly used abbreviations such as ‘NY, NY’ are acceptable.
F. MANAGING OWNER: Name, e-mail address and telephone number of the owner to whom the Coast Guard should send correspondence and their
Social Security Number (SSN) or Tax Identification Number (TIN). SSN or TIN IS REQUIRED. Only an owner or part owner can be the managing
owner. For vessels owned by a corporation the corporation is the managing owner. For a trust arrangement, the trustee is the managing owner.
For a Partnership or a LLC, the name of the Partnership or the LLC should be shown.
G. ADDRESS OF MANAGING OWNER: Enter the mailing address. If physical (street) address differs from mailing address, enter BOTH.
H. NAME(S) AND SOCIAL SECURITY NUMBER(S) OR TAX I.D. NUMBER(S) OF OTHER OWNERS: All persons/entities (other than managing
owner) who own an interest in the vessel. If no owners other than the managing owner, leave blank. Click icon for attachment if application covers
multiple owners.
I.

PURPOSE OF APPLICATION: Check applicable blocks to show purpose of application. If vessel has never been documented, check Block #5
and provide ALL requested information known about the vessel's place and year of build, hull material, approximate length and previous names and
numbers. If this information is unknown, please indicate.

J. ENDORSEMENTS: Check the appropriate block(s) to indicate all endorsement(s) sought on this application.
K. PRIMARY SERVICE & HORSEPOWER: Select only ONE service for which the vessel will be primarily used and insert horsepower.
L. CITIZENSHIP: Vessel must be owned by a U.S. citizen eligible for the endorsement(s) sought. Select the section that describes the type of entity
that owns the vessel. Citizenship for all owners must be provided.
INDIVIDUAL: Includes native born and naturalized U.S. citizens.
GOVERNMENT ENTITY: Includes Federal, State, Territory, Possession or Subdivision.
CORPORATION: Complete all items that apply.
LIMITED LIABILITY COMPANY (LLC): Complete Equity Section and choose type. For member managed LLC, a list of members is required. Click
icon for attachment if application covers multiple members.
PARTNERSHIP: Complete Equity Section and choose type. A list of all general partners is required. Click icon for attachment if application covers
multiple general partners.
CORPORATIONS QUALIFIED UNDER 46 CFR 68.01 OR OWNED BY A NOT-FOR-PROFIT OIL RECOVERY COOPERATIVE:
Attach a copy of the Certificate of Compliance or Letter of Qualification issued by the Director, NVDC.
JOINT VENTURE/ASSOCIATION: A list of all joint venturers/members is required. The percentage held by each need not be shown. Click icon for
attachment if application covers multiple joint venturers/members.
TRUST ARRANGEMENT: All trustees must be U.S. citizens. If applicable, each beneficiary with an enforceable interest must be a citizen. A list of
all trustees (except managing owner) and beneficiaries with an enforceable interest is required. Click icon for attachment if application covers
multiple trustees/beneficiaries with an enforceable interest.
M. CERTIFICATION: Complete as appropriate. The law provides severe penalties for false statements against both the person (including agents)
making the statement and against the vessel for which it is made.
NOTE: When applying for Fishery and/or Coastwise endorsement(s), see item 5.

READ THE PRIVACY ACT STATEMENT AT THE END OF THE CG-1258.
ADDITIONAL INFORMATION ABOUT DOCUMENTATION MAY BE FOUND AT OUR WEBSITE
http://www.uscg.mil/hq/cg5/nvdc/ and in 46 CFR Parts 67, 68 and 69.
YOU MAY ALSO CONTACT OUR OFFICE AT: 800-799-8362 OR BY MAIL AT U. S. COAST GUARD,
NATIONAL VESSEL DOCUMENTATION CENTER, 792 TJ JACKSON DRIVE, FALLING WATERS, WV 25419.

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