Fillable Cg-1280 - U.s. Coast Guard printable pdf download

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard

OMB No: 1625-0027

VESSEL RENEWAL NOTIFICATION

Form Expires: 07/31/2019

APPLICATION FOR RENEWAL

NATIONAL VESSEL DOCUMENTATION CENTER

RETURN TO:

PO BOX 1119

FALLING WATERS, WV 25419-1119

NOTICE: A FEE OF $26 PER VESSEL IS REQUIRED TO RENEW CURRENT CERTIFICATES OF DOCUMENTATION (CODS).

RENEWAL REQUESTS RECEIVED UP TO 30 DAYS AFTER THE EXPIRATION DATE OF THE COD WILL BE CONSIDERED 'LATE' AND WILL

REQUIRE PAYMENT OF A $5 LATE FEE (TOTAL PAYMENT OF $31.00).

RENEWAL REQUESTS RECEIVED 31 DAYS AFTER THE EXPIRATION DATE OF THE COD WILL RESULT IN THE COD BEING 'EXPIRED' AND WILL

REQUIRE REINSTATEMENT, WITH A PAYMENT OF $84.00. FOR MORE INFORMATION ON REINSTATEMENT, VISIT OUR WEBSITE AT

INSTRUCTIONS AND FORMS

REPLACEMENT AND REINSTATEMENT DOCUMENTATION.

PAYMENT OPTIONS

PAY ONLINE (single vessels only): To pay electronically, visit our website at

Order Products Online

Renew (or Late Renewal) and

follow instructions. You will need your Official Number to complete the payment process.

CUSTOMERS WHO PAY ONLINE ARE NOT REQUIRED TO SUBMIT A SEPARATE CG-1280.

PAY BY CREDIT CARD, CHECK OR MONEY ORDER (single vessels and/or Fleets): If paying by credit card, submit completed CG-1280 and CG-7042

AUTHORIZATION FOR CREDIT CARD TRANSACTIONS. IF PAYING BY CHECK OR MONEY ORDER, SUBMIT COMPLETED CG-1280 AND CHECK OR

MONEY ORDER PAYABLE TO: U.S. COAST GUARD

COMPLETING THE CG-1280:

If the CG-1280 was mailed to you, sign, date and indicate Capacity of Person signing. Enter change of address information if applicable.

If you obtained a blank, fillable form from our website, insert name and address in upper left corner of form to the left of the NVDC return address. Enter change

of address information below, if applicable. Sign, date, indicate Capacity of Person signing AND enter Vessel Name and Official Number in block titled VESSEL

NAME AND OFFICIAL #.

NOTE: Contact the National Vessel Documentation Center at (800) 799-8362 or (304) 271-2400 Eastern Standard Time to make any change other than address.

Mail completed form and payment to the address listed above, or e-mail to

VDC-PF-NVDCRENEWALS@USCG.MIL

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 5 MINUTES. YOU MAY SUBMIT ANY COMMENTS CONCERNING THE ACCURACY OF THIS

BURDEN ESTIMATE OR ANY 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 20593.

PLEASE INDICATE ADDRESS CHANGE BELOW, IF ANY. (A PHYSICAL ADDRESS IS REQUIRED WHEN USING A POST OFFICE BOX.)

PRIVACY ACT STATEMENT

1. AUTHORITY: 5 U.S.C. 301, DEPARTMENTAL REGULATIONS; 46 U.S.C. CHAPTER 121, DOCUMENTATION OF VESSELS.

2. PURPOSE: INFORMATION IS REQUIRED TO RENEW VESSEL CERTIFICATES OF DOCUMENTATION (COD).

3. ROUTINE USES: AUTHORIZED USCG PERSONNEL WILL USE THIS DATA TO VERIFY VESSEL’S OWNER/AGENT INFORMATION AND TO ACCOUNT FOR RENEWAL FEES. ANY DISCLOSURES

OF DATA WITHIN THIS RECORD WILL BE MADE IN ACCORDANCE WITH DHS/USCG-013, MARINE INFORMATION FOR SAFETY AND LAW ENFORCEMENT (MISLE), 74 FEDERAL REGISTER

(FR) 30305, JUNE 25, 2009, AND DHS/ALL-007 ACCOUNTS PAYABLE SYSTEM OF RECORDS, 80 FEDERAL REGISTER (FR) 58286, SEPTEMBER 28, 2015.

4. CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: VOLUNTARY. HOWEVER, FAILURE TO PROVIDE THE REQUESTED INFORMATION MAY RESULT IN THE EXPIRATION OF YOUR

COD AND LATE FEES BEING ASSESSED.

NAME

E-MAIL ADDRESS

PHYSICAL ADDRESS

P.O. BOX

CITY, STATE, ZIP

POTENTIAL PENALTIES FOR FALSE STATEMENTS OR REPRESENTATION BY OWNER OR REPRESENTATIVE: VESSEL FORFEITURE (46 USC 12151) & FINE AND/OR IMPRISONMENT (18 USC 1001).

I CERTIFY THAT THE RECITATIONS CONCERNING THE VESSEL: NAME, TONNAGE, DIMENSIONS, PROPULSION, OWNERSHIP, HAILING PORT, RESTRICTIONS,

ENTITLEMENTS, REMARKS AND ENDORSEMENTS CONTAINED IN THE CERTIFICATE OF DOCUMENTATION REMAIN ABSOLUTELY THE SAME.

CONTACT THE

NATIONAL VESSEL DOCUMENTATION CENTER FOR ANYTHING OTHER THAN CHANGE OF ADDRESS.

VESSEL NAME AND OFFICIAL #

AUTHORIZED SIGNATURE

CAPACITY OF PERSON SIGNING (OWNER/AGENT)

DATE

CG-1280 (08/16)

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