Form Cg Npfc-Ca1 - Optional Osltf Claim Form - Department Of Homeland Security

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Department of Homeland Security
U.S. Coast Guard
Optional OSLTF Claim Form
CG NPFC-CA1
ATTN: CLAIMS ADJUDICATION
(Rev. April 03)
NATIONAL POLLUTION FUNDS CENTER
US COAST GUARD STOP 7100
4200 WILSON BLVD STE 1000
ARLINGTON VA 20598-7100
PURPOSE: This form may be used for submitting claims to the U.S. Coast Guard, National Pollution Funds Center, for potential
compensation from the Oil Spill Liability Trust Fund for uncompensated removal costs or damages resulting from an inci-
dent under the Oil Pollution Act of 1990 (OPA). You may use your own version of this form. PLEASE PRINT OR TYPE:
1. Claimant Information:
Name:
_______________________________________________________________________
Address:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Home Tel. #:
____________________________
Work Tel. #: _____________________________
Fax Number:
____________________________
E-mail: _________________________________
2. Incident Information:
Date:
Time: ______________ NRC Report #:_________________
Name of vessel or facility causing damage: ____________________________________________________________________
Geographic location of incident: ____________________________________________________________________________
Brief description of the incident: ____________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
3. Type(s) of claim(s) and total amount for costs and damage(s) claimed:
$ _______________ Removal Costs
$ _____________ Subsistence Use
$_____________ Profits & Earning Capacity
$ _______________ Public Services
$_____________ Natural Resources
$ ____________ Government Revenues
$ _______________ Real or Personal
Property
$ _______________________________ Total Amount Claimed
4. Has claimant communicated with the responsible party?
No
Yes
:
5. Has the claim been submitted to the responsible party?
No
Yes Date Submitted
_____________________
6. If the claim has been submitted to the responsible party, what action has the responsible party taken?
No Action
Denied
Other – Explain:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
7. Has claimant commenced an action in court to recover costs which are the subject of the claim?
No
Yes
If yes, provide the name, address, phone number of your attorney, the court in which action is
pending and the civil action number: _________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
CG NPFC-CA1 (APR 03)
Page 1 of 2
Initials/Date:
/
Previous edition can be used

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