Sole Proprietorship

OMB No. 2133-0530
Expiration: January 31, 2020
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a
penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless
that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information
collection is 2133-0530. Public reporting for this collection of information is estimated to be approximately 5.90 hour per
response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to
this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Maritime
Administration, MAR-390, 1200 New Jersey Avenue, SE, Washington, DC 20590.

Affidavit of U.S. Citizenship
OF
(NAME OF SOLE PROPRIETORSHIP)

State of

)
) ss.:
)

County of

I, (Name), of (Physical residence address, city, and state), being duly sworn, depose
and say:

1. That I am the sole proprietor of (Name of Sole Proprietorship) (hereinafter
called the ``Proprietorship'') a sole proprietorship organized and existing under the laws
of the State of ________, with offices at (Business address). [Evidence of continuing
U.S. citizenship status for vessel owners should be filed within 45 days of the annual
documentation renewal date. Other parties required to provide evidence of U.S.
citizenship status must file within 30 after the original affidavit.];
2. That I am authorized by and in behalf of the Proprietorship to execute and
deliver this Affidavit of U.S. Citizenship;
3. That the names of the sole proprietor and any officers or other individuals who
are authorized to bind the Proprietorship are as follows: 1
Name

Title

Name

Title

1

Affidavit.

Date and Place of Birth (City/State)
Date and Place of Birth

Offices that are currently vacant should be noted when listing Officers and Directors in the

Each of said individuals is a Citizen of the United States by virtue of birth in the United
States, birth abroad of U.S. citizen parents, by naturalization, or as otherwise authorized
by law, except (give name and nationality of all Non-Citizen officers and directors, if
any).
4. That 100% of the ownership in the Proprietorship is vested in a Citizen of the
United States free from any trust or fiduciary obligation in favor of any person not a
Citizen of the United States; that there are no stock books or records equivalent to a
corporation; that through no contract or understanding is it so arranged that any of the
voting power of the Proprietorship may be exercised, directly or indirectly, in behalf of
any person who is not a Citizen of the United States; and that by no means whatsoever, is
any interest in the Proprietorship conferred upon or permitted to be exercised by any
person who is not a Citizen of the United States; and

5. That the affiant has submitted all of the necessary documentation required
under 46 C.F.R. ' 356.13 in connection with this Affidavit of U.S. Citizenship for the
vessels herein identified.
6. That affiant has carefully examined this affidavit and asserts that all of the
statements and representations contained therein are true to the best of his knowledge,
information, and belief.

(Name and title of affiant)

.
(Signature of affiant)

Date

Penalty for False Statement: A fine or imprisonment, or both, are provided for violation
of the proscriptions contained in 18 U.S.C. 1001 (see also, 18 U.S.C. 286, 287 and 46
App. U.S.C. §12122).