UNITED STATES OF AMERICA DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard LOST CREDENTIAL AFFIDAVIT

CG-5800H (08/14)

Address of Coast Guard Unit

Investigating Officer

Name and Address of Mariner

Coast Guard Enforcement Activity Number:

DateSignatureType or print name

LOST CREDENTIAL AFFIDAVIT

Telephone

, hereby notify the U.S. Coast Guard that I have lost the following listed

Coast Guard issued Credential(s).

1. I,

2. Circumstances concerning the loss, to the best of my knowledge, and my attempts to find the missing Credentials are as follows:

3. I further certify that if this (these), or any other Coast Guard issued Credentials are located, it (they) will be promptly surrendered to the Coast Guard.

Privacy Act Statement The legal authority for the collection of information on this form is authorized by 46 U.S.C. Chapter 77 and 33 C.F.R. Part 20. The information provided will be used to advocate your position in this administrative proceeding. Unless part of mandatory discovery, submission of the information on this form is voluntary.  You are solely responsible for the manner in which you want to present your own case.  This document will become part of the official record, which can be viewed by the public. 33 C.F.R. § 20.903.