CG-7043 Abstract of Title/Certified Cod Request

DEPARTMENT OF HOMELAND SECURITY

OMB No: 1625-0027

U.S. Coast Guard
ABSTRACT OF TITLE/CERTIFIED COD REQUEST
A.

Expires: 06/30/2016

PLEASE CHECK BOX IF REQUESTING MULTIPLE DOCUMENTS AND USE PAGE 2

B. VESSEL USE/ENDORSEMENT (CHECK ONE:)

RECREATION

COMMERCIAL

C. OFFICIAL # (IF AWARDED)

D. HULL IDENTIFICATION # OR OTHER UNIQUE IDENTIFIER (IF ANY)

E. VESSEL NAME

F. OWNER’S NAME

G.

ABSTRACT OF TITLE (AT)

CERTIFIED COPY OF CERTIFICATE OF DOCUMENTATION (COD)

H. BUSINESS/ORGANIZATION NAME (IF APPLICABLE)

I.

REQUESTOR’S NAME

J. REQUESTOR’S ADDRESS

K. REQUESTOR’S FAX NUMBER

L. REQUESTOR’S TELEPHONE NUMBER

M. E-MAIL ADDRESS

N. CREDIT CARD HOLDER’S NAME

O. CREDIT CARD NUMBER (WE ACCEPT VISA, MASTERCARD, AMERICAN EXPRESS
OR DISCOVER)

P. EXPIRATION DATE

Q. FEE INFORMATION:
$25 PER AT x

__________________

ATS ORDERED

=

$ __________________

$ 4 PER COD x

__________________

CODS ORDERED

=

$ __________________

R. TOTAL AUTHORIZED CHARGE TO CREDIT CARD

S. REQUEST RETURN BY:

USPS

FAX

$ __________________

E-MAIL

FOR COAST GUARD USE ONLY
T. NAME OF PERSON TAKING REQUEST

U. DATE

PRIVACY ACT STATEMENT
IN ACCORDANCE WITH 5 U.S.C. 552(a), 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 PURPOSE FOR WHICH THIS INFORMATION IS TO BE USED IS TO COLLECT USER FEES DIRECTLY ASSOCIATED WITH THE NATIONAL
VESSEL DOCUMENTATION CENTER FOR WHICH APPLICATION FOR DOCUMENTATION IS MADE.
3. 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 5 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.

CG-7043 (04/12)

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ATTACHMENT TO
ABSTRACT OF TITLE/CERTIFIED COD REQUEST
OFFICIAL #

HULL IDENTIFICATION #

VESSEL NAME OR
OWNER’S NAME

AT
$25.00

COD
$4.00

REC

COM

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CG-7043 (04/12)

Previous Edition Obsolete

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