CG-5585 (10/19) Application for Vessel Certificate of Financial Responsi

DEPARTMENT OF HOMELAND SECURITY
U.S. COAST GUARD

OMB No.: 1625-0046

APPLICATION FOR VESSEL CERTIFICATE OF FINANCIAL RESPONSIBILITY
(WATER POLLUTION)
PART I: GENERAL
INSTRUCTIONS
Please type or print and submit this application, together with all evidence of financial responsibility required under 33 CFR § 138.80 and all
fees required under 33 CFR § 138.130, to the U.S. Coast Guard, National Pollution Funds Center (Cv) MS7100, 2703 Martin Luther King
Jr. Ave., SE, Washington, D.C. 20593-7605 (Telephone: (202) 795-6130, Fax: (202) 795-6123). Applicants must answer all applicable
questions. If a question does not apply, answer "not applicable." Incomplete applications will be returned. If additional space is required,
supplemental sheets may be attached. The completed application and all supporting information must be provided in the English language,
and must express all monetary terms in United States Dollars. As an alternative to using this form, you may use the E-COFR system,
available through the NPFC's Web site at https://npfc.uscg.mil/cofr.
1. (a) Legal Name of Applicant (Name of Responsible Operator of all Vessels
Listed in Part II):

THIS SPACE FOR USE BY USCG ONLY

(b) English Equivalent of Legal Name (if customarily written in language other
than English):
(c) Trade Name (if any):

2. Is this the first time the above-named applicant is submitting application Form
CG-5585?
Yes

No

If no, what Coast Guard Control Number was assigned to the first application
Form CG-5585?
3. State applicant's legal form of organization (i.e., operating as an individual, corporation, partnership, association, joint stock company
business trust, or other organized group of persons [whether incorporated or not], or as a receiver, trustee, or other liquidating agent)
and briefly describe applicant’s current business activities and length of time engaged therein:

(a) Indicate if a corporation, association,
or other organization:

U.S. or Foreign State in which incorporated or
organized:

Date of incorporation or organization:

(b) If a partnership, provide name and address of each partner:

4. Name and address of applicant's U.S. agent or other person authorized by applicant to accept service of process and receipt of notices
of designations and presentations of claims in the U.S. (collectively referred to as "service of process") (NOTES: See Part IV; U.S.
applicants may appoint themselves as agent, eliminating the need to complete Part IV):

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 completing this form is 30 minutes. You may submit any comments concerning the accuracy of this
burden estimate or any suggestion for reducing the burden to the: Commandant (NPFC), U.S. Coast Guard, 2703 Martin Luther King Jr. Ave., SE,
Washington, D.C. 20593-7605 or Office of Management and Budget, Paperwork Reduction Project (1625-0046), Washington, DC 20503.

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PART II: EVIDENCE OF FINANCIAL RESPONSIBILITY
5. List all vessels that require Certificates of Financial Responsibility under 33 CFR 138.12:
NAME OF VESSEL
(a)

TYPE OF
VESSEL
(See Note 1
below)

(b)

HULL TYPE
(See Note 2
below)

(c)

COUNTRY
OF
REGISTRY
(d)

DOCUMENTATION NUMBER (for
U.S. Vessels) / INTERNATIONAL
MARITIME ORGANIZATION (IMO)
NUMBER (for Foreign Vessels)
(e)

GROSS
TONS
(f)

NOTE 1: Please designate the Type of Vessel in column 5(b) by using a number from one of the following categories:
CARGO VESSELS, SELF-PROPELLED
Breakbulk freighter =10
Containership * = 11
Roll on-roll off = 12
Barge carrier (e.g., lash, seabee) = 13
Combination breakbulk containership * = 14
Combination roll on-roll off containership * = 15
Combination barge carrier containership * =16
Tanker = 17
Dry bulk carrier = 18
All other self-propelled cargo vessels = 19
Oil/bulk/ore carrier (OBO) = 20

PASSENGER VESSELS
Passenger vessel** = 30
Combination passenger/cargo vessel** = 31
Ferry** = 32
RECREATIONAL VESSELS
All types of pleasure craft = 40

UTILITY CRAFT
Tank barge = 50
Tug and towboat = 51
Barge and scow = 52
Drilling rig = 53
Fishing vessel = 54
Factory vessel = 55
Research vessel = 56
All other utility craft*** = 57
MISCELLANEOUS
Vessels not otherwise
specified = 60

* Containership categories should be assigned only to vessels having fixed container cells or regularly carrying multi-tier container
deckloads.
** Passenger categories should be assigned only to vessels carrying more than 12 passengers for hire.
*** Includes floating cranes, dredges, docks, etc.
NOTE 2: For Vessel Types 17 (Tanker), 20 (Oil/bulk/ore carrier), 50 (Tank Barge), or 53 (Drilling Rig), please designate the Hull Type as
defined in 33 CFR 138.220, in column 5(c), by using a letter from one of the following categories:
S = SINGLE HULL, including a single hull vessel fitted with double sides only or a double bottom only
D = DOUBLE HULL
5(g). Provide owner information for each vessel below. Enter “SAME” in the OWNER column if the owner is the same as the operator:
NAME OF VESSEL

CG-5585 (10/19)

OWNER

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OWNER'S MAILING ADDRESS

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6. Items 7 through 11 are methods of establishing and maintaining evidence of financial responsibility. Answer only the item(s) which are
applicable to this application:
Insurance
(Answer item 7)

Surety Bond
(Answer item 8)

Financial Guaranty
(Answer item 9)

Self-Insurance
(Answer item 10)

Other Services
(Answer item 11)

7. Name and address of applicant's insurance guarantor (Insurance Guaranty Form CG-5586 or Master Insurance Guaranty Form CG5586-1 must be filed before a Certificate will be issued):

8. Name and address of applicant's surety bond guarantor (Surety Bond Guaranty Form CG-5586-2 must be filed before a Certificate will
be issued):

Total amount of surety bond guaranty:

$
9. Name and address of applicant's financial guarantor (Financial Guaranty Form CG-5585-3, or Master Financial Guaranty Form
CG-5586-4 and all financial data and other information required by 33 CFR 138.80(b)(4) must be filed before a Certificate will be
issued):

Financial Guarantor's fiscal year:
____________________
(Month)
(Day)

to ____________________
(Month)
(Day)

10. If applicant intends to qualify as a self-insurer, attach all financial data and other information required by 33 CFR 138.80(b)(3) and
indicate fiscal year. (All required information must be filed before a Certificate will be issued):

____________________
(Month)
(Day)

to

____________________
(Month)
(Day)

11. If applicant intends to qualify through other evidence, supply all information required by 33 CFR 138.80(b)(5):

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PART III: DECLARATION
12. Applicant's mailing address (street number, post office box, city,
state or country. Indicate zip code if in the U.S.):

13. Telefax number:
14. Name and title of the official signing this application:

15. Address of principal office in the U.S. (if any):

16. Telephone no. (include area code):

17. E-mail address:

I declare that I have examined this application, including any accompanying schedules and statements, and, to the best of my knowledge
and belief, it is true, correct, and complete. Furthermore, the applicant named in item 1(a) of Part I above is the responsible operator of
all vessels now listed in or later added to this application. I agree that in the event the agent designated in item 4 of Part I above, or that
agent's replacement as may be designated later with the approval of the Director, U.S. Coast Guard National Pollution Funds Center,
cannot be served due to death, disability, unavailability, or similar event, the Director, U.S. Coast Guard National Pollution Funds Center,
is considered the agent for service of process. I have signed this application in my capacity as an authorized official of the applicant, or,
if acting under a power of attorney, pursuant to the power vested in me by the applicant as evidenced by the attached power of attorney.

IMPORTANT

SIGNATURE REQUIRED
Signature of Authorizing Official:

Date:

NOTES
• Please be sure that Parts I, II, and III have been completed in full, and that Part III has been dated and signed. Then proceed to
Part IV (on Page 5).
• NO CERTIFICATE WILL BE ISSUED UNLESS A COMPLETED APPLICATION FORM HAS BEEN RECEIVED, PROCESSED, AND
APPROVED.
Comments:

Any person who knowingly and willfully makes a false statement in this application is subject to the sanctions prescribed in 18
U.S.C. 1001.
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PART IV: CONCURRENCE OF AGENT
INSTRUCTIONS
• Part IV(A) must be completed by the person designated in item 4 of Part I to serve as applicant's United States agent for service of
process.
• Part IV(B) must be completed by the applicant. After Parts IV(A) and IV(B) are completed, Part IV should be submitted to the Director,
Coast Guard National Pollution Funds Center, by the applicant or by the agent, either separately or together with Parts I, II, and III. (Part
IV need not be completed if the agent designated in item 4 of Part I already has submitted to the U.S. Coast Guard an acceptable
blanket Concurrence of Agent, agreeing to serve on behalf of certain applicants who designate that agent. Part IV also need not be
completed if the applicant is a United States entity and has appointed itself as agent in item 4 of Part I.)

PART IV(A) (TO BE COMPLETED BY PERSON DESIGNATED AS U.S. AGENT)
It is hereby agreed that ________________________________________________________________________________
(Name of person designated as applicant's U.S. agent)

shall serve as the applicant's United States agent for service of process for purposes of 33 CFR part 138. This designation and agreement
shall cease immediately in the event the applicant designates a new agent acceptable to the Director, Coast Guard National Pollution
Funds Center.
Date:

Signature of designated agent:
Title of designated agent:

Business address:

PART IV(B) (TO BE COMPLETED BY APPLICANT)
Name of applicant:
(Should be the same name given on item 1(a))

Date:

Signature of authorized official:
(Should be signed by the same person who signed Part III)

Name and title of authorized official:
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. §552a(e)(3), this Privacy Act Statement serves to inform you of why DHS is requesting the information on this form.
AUTHORITY: OPA'90; 33 U.S.C. 2702(a); 33 U.S.C. 2704; 33 U.S.C. 2716(b); 42 U.S.C. 9607; and 42 U.S.C. 9608(a).
PURPOSE: The Coast Guard will use this information as evidence that the owners and operators, including demise charterers, of certain vessels have
established and are maintaining evidence of financial responsibility (i.e., ability to pay) sufficient to meet the maximum amount of liability to which they could
be subjected under the Oil Pollution Act of 1990 (33 U.S.C. 2702(a); 33 U.S.C. 2704) (OPA'90), and the Comprehensive Environmental Response,
Compensation and Liability Act of 1980, as amended (42 U.S.C. 9607) (CERCLA), in the event of a discharge, or substantial threat of discharge, of oil or a
release, or threatened release, of hazardous substances, into the navigable waters, adjoining shorelines or the exclusive economic zone of the United
States.
ROUTINE USES: This information will be used by and disclosed to Coast Guard personnel and contractors or other agents who need the information to
assist in activities related to the OPA'90 and CERCLA evidence of financial responsibility requirements, including personnel responsible for the storage and
ultimate disposal of the information. Any external disclosures of data within this record will be made in accordance with DHS/USCG-013, Marine Information
for Safety and Law Enforcement, 74 Federal Register 30305, June 25, 2009.
DISCLOSURE: Furnishing this information is voluntary; however, if the requested information is not furnished, the Coast Guard will be unable to certify
compliance by vessel owners and operators, including demise charterers, with the applicable OPA'90 and CERCLA evidence of financial responsibility
requirements. This may result in the withholding or revocation of vessel clearance and other sanctions as specified within OPA'90, 33 U.S.C. 2716(b) and
42 U.S.C. 9608(a).

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