CG NPFC-CA1 (AUG 19) 

Previous edition can be used 

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Department of Homeland Security

CG NATIONAL POLLUTION FUNDS CENTER (CA)

US COAST GUARD STOP 7605 

2703 MARTIN LUTHER KING JR AVE SE 

WASHINGTON DC 20593-7605

Optional OSLTF Claim Form

CG NPFC-CA1 

(Rev. AUG 19) 

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 incident 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. #:

Fax Number:

Work Tel. #:

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 $ 

$ Natural Resources $ 

Profits & Earning Capacity $ 

Government Revenues $ 

Public Services

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 (AUG 19) 

Previous edition can be used 

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Optional OSLTF Claim Form CG NPFC-CA1

8. Has claimant submitted or planned to submit the loss to an insurer? No Yes Please provide

the name, address, and phone number of your insurer, the policy number, and explain any compensation received:

9. Description of the nature and extent of damages claimed (Attach additional information as necessary):

10. Description of how the incident caused the damage:

11. Description of actions taken by claimant/representative to avoid or minimize damages:

12. Witnesses:

Name: Tel. No.: 

Address:

Name:

Address:

Tel. No.:

13. List Documents or Attachments (Attach additional information as necessary):

a.

b.

c.

d.

e.

I, the undersigned, agree that upon acceptance of any compensation from the Fund, I will cooperate fully with the United States in any 

claim or action by the United States to recover the compensation. The cooperation shall include, but is not limited to, immediately 

reimbursing to the Fund any compensation received from any other source for the same costs and/or damages and, providing any 

documentation, evidence, testimony, and other support, as may be necessary for the Fund to recover such compensation. 

I, the undersigned, certify that, to the best of my knowledge and belief, the information contained in this claim represents all material 

facts and is true. I understand that misrepresentation of facts is subject to prosecution under Federal law (including but not limited to 18

U.S.C. 287 & 1001 and 31 U.S.C. 3729).

14. 15.

Claimant’s Signature Date Legal Representative Date

Printed Name of Signer: Title/Legal Capacity: 
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PRIVACY 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. 

DISCLOSURE: Decision to submit a claim is voluntary; but, if proper information is not furnished by the 

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 representation 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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8. Indicate if claimant is pursuing payment from an insurance carrier for costs that are

included in the claim. If yes, provide all information that will enable us to contact the insurer and identify the claimant’s policy.

9. Provide detailed information, evidence, and documentation that describes the extent of the

damage(s) claimed. Attach copies, if necessary, of all pertinent information.

10. Provide any information, evidence, and documentation that will help describe how the oil

spill, or threat of oil spill, caused the removal costs and/or damage(s) claimed.

11. Provide any information, evidence, and documentation that describe the actions of the

claimant or any other person on the claimant’s behalf to reduce or avoid the damage(s)

claimed.

12. Provide the name, address and telephone number (if known) of any witness to the damage(s) claimed. On a separate page provide a summary of each witness's knowledge of the

damage(s) claimed or the incident causing or suspected of causing the damage(s) claimed.

13. If you provide additional documents, please list them here or on a separate piece of paper.

14. If the claimant is an individual, that person must sign the claim. If the claimant is a

corporation, an officer of the company must sign the claim. All signatures must be in ink

to be valid.

15. If the claim is presented by a legal representative, that legal representative must also sign

the claim. Provide the complete address and phone number of that legal representative.

Submit your claim, with any necessary information, evidence, and documentation to: 

DEPARTMENT OF HOMELAND SECURITY

CG NATIONAL POLLUTION FUNDS CENTER (CA) 

US COAST GUARD STOP 7605 

2703 MARTIN LUTHER KING JR AVE SE 

WASHINGTON DC 20593-7605

Claims for Natural Resource Damages or for Loss of Subsistence Use of Natural Resources may be addressed to “ATTN: NATIONAL RESOURCE DAMAGES CLAIMS 

DIVISION”.

We recommend that you keep the Privacy Act Statement and a copy of the claim for your files.