Incident Report and Transmittal Page 1

From: Date:

To: Director, National Pollution Funds Center

Subj: Financial Summary Report for Federal Project No. (FPN)/ CERCLA Project No. (CPN)/ Disaster Project No.(DPN):

Incident Information

FPN/CPN/DPN: Date of Incident: 

MISLE Case No.: Date OPA/CERCLA/Stafford Act Actions Started: 

MISLE Activity No.: Date OPA/CERCLA/Stafford Act Actions Completed: 

Location of Incident: 

Was this an Actual Discharge? Or Substantial Threat of a Discharge?

Source of Discharge/SubThreat: Product (Oil / Hazmat): Quantity Discharged:

Waterway or Resource Affected:

Describe theIncident: 

Financial Information

Total Authorized Ceiling: 

Total CG Direct Costs: 

Total CG Indirect Costs:

Checklist

Yes ☐ No ☐ N/A ☐ Has source been designated for potential Damage/Removal claims?

Yes ☐ No ☐ N/A ☐ Are copies of the NOFI, NOFA, Admin Order, or any other related correspondence attached?

Yes ☐ No ☐ N/A ☐ Has the FOSC ensured that personnel captured on the CG-5136 were only involved in oil response/mitigation?

Yes ☐ No ☐ N/A ☐ Is all equipment physically used in the response area listed on the CG-5136?

Yes ☐ No ☐ N/A ☐ Are copies of the ALMIS printouts provided for each resource, i.e. Aircraft, Cutters, and Boats?

Yes ☐ No ☐ N/A ☐ Are all the TONOs “accounted for or noted” on the dailies?

Yes ☐ No ☐ N/A ☐ Have all remaining unused funds been de-obligated in FPD?

Prepared/Submitted By: Phone No.: 

FOSC or Response Department Head Approval*

Approved by:

FOSC/RDH Signature:

Revised: September 2018

*See NPFC Form 16480 - Case/Cost Doc Checklist
Incident Report Source Information Page 2 

Identification ‐ Vessels

Vessel name: Flag/Nationality:

Official number/Callsign/State number: Grosstons:

Home Port: Type of vessel: 

Master’s name:

US Agent: 

US Agent Address: 

US Agent ContactPhone: 

Identification – Facility

FacilityName:

FacilityAddress: 

Type of Facility: 

Responsible Parties

Owner

CompanyName: 

CompanyAddress: 

ContactName: 

ContactPhone: 

Notice of Designation

Notified of Designation? Yes No 

Date Notified?

Accepted Designation? Yes No 

Rejected Designation? Yes No 

Advertised? Yes No

Insurance Company

CompanyName: 

CompanyAddress: 

ContactName: 

ContactPhone: 

Notice of Designation

Notified of Designation? Yes No 

Date Notified?

Accepted Designation? Yes No 

Rejected Designation? Yes No 

Advertised? Yes No

Operator

CompanyName: 

CompanyAddress: 

ContactName: 

ContactPhone: 

Notice of Designation

Notified of Designation? Yes No 

Date Notified?

Accepted Designation? Yes No 

Rejected Designation? Yes No 

Advertised? Yes No

Other

CompanyName: 

CompanyAddress: 

ContactName: 

ContactPhone: 

Notice of Designation

Notified of Designation? Yes No 

Date Notified?

Accepted Designation? Yes No 

Rejected Designation? Yes No 

Advertised? Yes No

Attach copies of all designation letters and any otherrelated correspondence.

Revised: September 2018
List contractors that assisted in removal operations under the direction of the Federal On-Scene Coordinator.

Duplicate and enumerate for multiple contractors.

Incident Report Contractors Page 3

Company: 

Address: 

Contact: 

Phone:

Authorized Ceiling: 

Contract No.:

Revised: September 2018
List Government Agencies that assisted in Removal Operations under the direction of the Pre-Designated Federal On-Scene Coordinator

Duplicate and enumerate for multiple government agencies

Incident Report Other Government Agencies Page 4

(Federal, State and Local)

Agency:

Unit:

Address:

Contact:

Phone:

Authorized Ceiling:

Attach copy of certified contractor’s invoice(s)

Comments:

Revised: September 2018
List other person(s) or companies that are important to the case and not listed elsewhere.

Duplicate and enumerate for multiple key parties.

Incident Report Key Parties Page 5 

Person/Agency/Company: 

Address:

Contact:

Phone:

Relationship to the case:

Revised: September 2018
Incident Report and Transmittal Page 6 

Enclosures:

Revised: September 2018

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