Affidavit

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 LIMITED LIABILITY COMPANY)
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 (Title of office(s) held) of (Name of Limited Liability Company), a
limited liability company organized and existing under the laws of the State of ______
(hereinafter called the “Name of LLC''), with offices at (Business address), in evidence of
which formation a certified copy of the Certificate of Formation is filed herewith (or has
previously been filed with the Maritime Administration) together with a certified copy of the
Limited Liability Company Operating Agreement of (Name of LLC) dated ( Date ).
[Evidence of continuing U.S. citizenship status, including amendments to said Certificate and
Limited Liability Company Operating Agreement, should be filed at least 45 days prior to the
annual documentation renewal date for vessel owners. Other parties required to provide
evidence of U.S. citizenship status must file within 30 days after the annual meeting of the
stockholders or annually, within 30 days after the original affidavit if there has been no
meeting of the stockholders prior to that time.];
2. That I am authorized by and in behalf of (Name of LLC) to execute and deliver this
Affidavit of U.S. Citizenship;
3. That (Name of LLC) is a member managed limited liability company with officers
and/or directors;
4. That the names of the Chief Executive Officer, by whatever title, the Chairman of the
Board of Directors, President, Vice Presidents, Officers, Management Committee members or
other individuals who are authorized to act in the absence or disability of such individuals are as
follows: 1
Name

Title

Date and Place of Birth (City/State)

Name

Title

Date and Place of Birth

1

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

(The foregoing list should include the officers, whether or not they are also directors, and all
directors, whether or not they are also officers.) 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 NonCitizen officers, directors, and members of the Management Committee, if any). The
Operating Agreement of (Name of LLC ) provides that (Number) of the (directors or
members of the Management Committee) are necessary to constitute a quorum; therefore, the
Non-Citizen directors or members of the Management Committee named represent no more than
a minority of the number necessary to constitute a quorum.
5.That the information as to Members of (Name of LLC) upon which the (Name of
LLC) relies to establish that 75% of the ownership is vested in Citizens of the United States, is
as follows:
________________________________________________________________________
Name of Member Date and Place of Birth
Type of Member
Membership Interest

Total Membership Interest
______________________________

100%
__________________________________________

and that each of said individual Members is a Citizen of the United States by virtue of birth in
the United States, birth abroad of U.S. citizen parents, or as otherwise authorized by law, except
(give name and nationality for any above identified members who are not U.S. Citizens).
Note: Include applicable citizenship information of Members needed to establish 75% interest
in U.S. Citizens or attach separate affidavits for such Members.
6. That 75% of the interest in (Name of LLC), as established by the information herein
before set forth, is owned by Citizens of the United States; that the title to 75% of the shares of
(Name of LLC) is vested in Citizens of the United States free from any trust or fiduciary
obligation in favor of any person not a Citizen of the United States; that such proportion of the
voting power of (Name of LLC) is vested in Citizens of the United States; that through no
contract or understanding is it so arranged that more than 25% the voting power of (Name of
LLC) 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 (Name of LLC) in excess of
25% conferred upon or permitted to be exercised by any person who is not a Citizen of the
United States; and
7. 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.
8. 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.

2

(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).

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