CG-5542 (06/12) Optional Application for Filing

DEPARTMENT OF HOMELAND SECURITY

OMB No: 1625-0027

U.S. Coast Guard
OPTIONAL APPLICATION FOR FILING

Expires: 07/31/2019

(SEE INSTRUCTIONS AND PRIVACY ACT ON REVERSE)
1. VESSEL NAME (ATTACH SCHEDULE IF MORE THAN ONE VESSEL)

2. OFFICIAL NUMBER OR OTHER UNIQUE
IDENTIFIER

3. INSTRUMENT TYPE (CHECK ALL THAT APPLY)
PREFERRED MORTGAGE

ASSUMPTION

ASSIGNMENT

CHATTEL MORTGAGE

SUPPLEMENT

OTHER (DESCRIBE)

AMENDMENT

SUBORDINATION

4. NAME(S) AND ADDRESS(ES) OF GRANTOR(S)

(MORTGAGOR(S), ASSIGNOR(S), ASSUMING PARTY(IES), OR OTHER(S) - SEE INSTRUCTIONS)

INTEREST OWNED IN VESSEL OR HELD IN MORTGAGE AFFECTED BY ATTACHED INSTRUMENT _______%.
5. NAME(S) AND ADDRESS(ES) OF GRANTEE(S)

(MORTGAGEE(S), ASSIGNEE(S), OR OTHER(S) -- SEE INSTRUCTIONS)

PERCENTAGE OF VESSEL MORTGAGED OR MORTGAGE ASSIGNED __________ %.
6. AMOUNT

(100% UNLESS OTHERWISE STATED)

(100% UNLESS OTHERWISE STATED)

7. IDENTIFICATION ON INSTRUMENT ASSUMED, ASSIGNED, AMENDED, SUPPLEMENTED, SUBORDINATED, OR
OTHERWISE MODIFIED:
RECORDED BOOK:

PAGE:

FILE/RECORDED DATE:

TIME:

OTHER IDENTIFYING DATA:
8. CERTIFICATION AND ATTESTATION: I (WE) HEREBY CERTIFY THAT THE FACTS RECITED HEREIN ARE TRUE AND CORRECT. I (WE)
UNDERSTAND THAT THE U.S. COAST GUARD WILL RELY ON THOSE RECITATIONS IN INDEXING THE ATTACHED INSTRUMENT.

SIGNATURE(S): (SEE INSTRUCTIONS)
FOR THE GRANTOR(S)
____________________________________________________

FOR THE GRANTEE(S)
_________________________________________________________

____________________________________________________

_________________________________________________________

STATE: ___________
COUNTY: _________________________________
SUBSCRIBED AND SWORN BEFORE ME ON: ______________________________________
NOTARY PUBLIC: _____________________________________________________________
MY COMMISSION EXPIRES: ___________________________
(DATE)

WARNING: FALSE STATEMENT MAY RESULT IN FINE OR IMPRISONMENT PURSUANT TO TITLE 18 USC.
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INSTRUCTIONS
1. SELF-EXPLANATORY. A SCHEDULE MAY BE ATTACHED IF MORE THAN ONE VESSEL IS AFFECTED BY THE INSTRUMENT
ATTACHED.
2. LIST COAST GUARD ASSIGNED OFFICIAL NUMBER, MANUFACTURER’S HULL IDENTIFICATION NUMBER (HIN) ASSIGNED IN
ACCORDANCE WITH RULES IN 33 CFR, OR OTHER UNIQUE IDENTIFIER, (STATE MOTORBOAT NUMBERS ARE NOT
CONSIDERED UNIQUE IDENTIFIERS.)
3. SELF-EXPLANATORY.
4. GRANTOR. FOR PURPOSES OF THIS FORM, GRANTORS INCLUDE MORTGAGORS, ASSIGNORS, PERSONS ASSUMING
MORTGAGES, PERSONS GRANTING SUBORDINATION OF MORTGAGES. LIST ALL GRANTORS AND ADDRESSES. A SEPARATE
SCHEDULE MAY BE ATTACHED IF MORE ROOM IS NEEDED.
5. GRANTEE. FOR PURPOSES OF THIS FORM, GRANTEES INCLUDE MORTGAGEES, ASSIGNEES, PERSON FROM WHOM
MORTGAGES ARE ASSUMED, AND PERSON TO WHOM SUBORDINATION OF MORTGAGES ARE GRANTED. LIST ALL GRANTEES
AND ADDRESSES. A SEPARATE SCHEDULE MAY BE ATTACHED IF MORE ROOM IS NEEDED.
6. SELF-EXPLANATORY.
7. NOT USED FOR NEW CHATTEL OR PREFERRED MORTGAGES. MUST BE COMPLETED FOR ASSUMPTIONS, ASSIGNMENTS,
AMENDMENTS, OR OTHER INSTRUMENTS MODIFYING CHATTEL OR PREFERRED MORTGAGE FILED PREVIOUSLY OR
CONCURRENTLY.
8. REQUIRED SIGNATURES AND NOTARIZATION:
CHATTEL OR PREFERRED MORTGAGES, AMENDMENTS, OR SUPPLEMENTS: GRANTOR AND GRANTEE OR
PERSONS ACTING ON BEHALF OF THOSE ENTITIES.
-

ASSUMPTION OF MORTGAGE: ASSUMING PARTY AS GRANTOR, ORIGINAL MORTGAGOR AND MORTGAGEE AS
GRANTEES, OR PERSONS ACTING ON BEHALF OF THOSE ENTITIES.

-

SUBORDINATION AGREEMENT OR ASSIGNMENT: GRANTOR OF SUBORDINATION AGREEMENT OR ASSIGNMENT,
OR PERSON ACTING ON BEHALF OF THAT ENTITY.

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 10 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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