Form Cg Npfc-Ca1 - Optional Osltf Claim Form - Department Of Homeland Security Page 3
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4PRIVACY ACT STATEMENT
AUTHORITY:
33 U.S.C. 2713.
PRINCIPAL PURPOSE:
To aid the Coast Guard in adjudicating claims for
reimbursement of removal costs and damages from oil spills when the Responsible Party has not paid.
ROUTINE USES:
Information on reimbursements may be provided to the Internal Revenue Service for tax
purposes and may be provided to the Department of Justice for litigation against the Responsible Party.
Decision to submit a claim is voluntary; but, if proper information is not furnished by the
DISCLOSURE:
claimant, the Government may be unable to evaluate or pay a claim.
This information applies to all claims against the Oil Spill Liability Trust Fund, whether or not the Optional
OSLTF Claim Form is used.
OPTIONAL OSLTF CLAIM FORM — INSTRUCTIONS
Please provide all information, evidence, and documentation that supports the removal costs
and/or damage(s) claimed. Use additional sheets or pages, as necessary, to provide information,
evidence, and documentation. The following numbered paragraphs correspond to the numbers on
the optional claim form:
1.
Complete name, street, city, state, ZIP and phone number of the claimant (party that
incurred damage and is seeking reimbursement).
2.
If known, provide the following incident information on the oil spill or threat of oil spill
causing or suspected of causing the removal costs and/or damage(s) claimed:
The identity of the vessel, facility or entity causing or suspected of causing the incident.
Describe the geographic area and waterway directly affected by the oil spill or threat of
oil spill.
Briefly describe any known information regarding the occurrence of the oil spill or
threat of oil spill.
3.
Indicate the amounts by the type of claim(s) being submitted. Provide the total amount
claimed.
4.
Indicate if claimant has had any communication (written or verbal) with the entity causing
or suspected of causing the damage(s) claimed.
5.
Has the claimant or the claimant’s legal representative submitted the claim(s) to the entity
causing or suspected of causing the damage claimed? If yes, include the date submitted.
6.
If claim was submitted to the responsible party, indicate any response (written or verbal) or
any payment you have received. Provide the date the claim was submitted.
7.
Indicate if the claimant is pursing a claim(s) against the responsible party by legal repre-
sentation in a court of law. If yes, provide all information that will enable us to contact
your legal representative and identify your case.
*
* At the bottom of the first page of the form, please initial and date the page. *
*
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