CG-5542 (05/20)) Optional Application for Filing

DEPARTMENT OF HOMELAND SECURITY

OMB No: 1625-0027

U.S. Coast Guard
OPTIONAL APPLICATION FOR FILING

Expires: 04/30/2023

(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 BK/BATCH:

PG/DOC ID:

FILE 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

PURSUANT TO 5 U.S.C. § 552A(E)(3), THIS PRIVACY ACT STATEMENT SERVES TO INFORM YOU OF WHY THE U.S. COAST GUARD (USCG) IS
REQUESTING THE INFORMATION ON THIS FORM.
AUTHORITY: 46 U.S.C. CHAPTERS 121 AND 313; 46 C.F.R. PART 67.
PURPOSE: TO PUBLISH AND PROVIDE A PUBLIC RECORD (AVAILABLE FOR PUBLIC INSPECTION/COPYING) OF THE FILING AND RECORDING
OF A MORTGAGE OR RELATED INSTRUMENT FOR A VESSEL WHICH IS DOCUMENTED, WILL BE DOCUMENTED, OR HAS BEEN DOCUMENTED
PURSUANT TO 46 U.S.C. CHAPTER 121.
ROUTINE USES: AUTHORIZED USCG PERSONNEL WILL USE THIS INFORMATION TO MAKE A DETERMINATION FOR THE FILING AND
RECORDING OF THE PROPERLY COMPLETED INSTRUMENTS TO WHICH FORM IS ATTACHED AS DEFINED IN 46 C.F.R. PART 67.231(C). 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 (FR) 30305, JUNE 25, 2009.
DISCLOSURE: FURNISHING THIS INFORMATION IS VOLUNTARY. HOWEVER, FAILURE TO PROVIDE THE INFORMATION REQUESTED MAY
RESULT IN DENIAL OF THE APPLICATION, 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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