DECLARATION IN LIEU OF AFFIDAVIT FOR DUPLICATE

MCP-FM-NMC1-182 (01)

DECLARATION IN LIEU OF AFFIDAVIT FOR DUPLICATE DOCUMENT REQUEST

In accordance with CG-MMC Policy Letter 01-20 and 46 Code of Federal Regulations (CFR) Section

10.229, mariners applying for a duplicate credential must submit an affidavit describing the

circumstances of the loss. The affidavit is evidence that the applicant is affirming that the information

provided is true and correct.

The affidavit may be submitted in writing or electronically. When submitted, this information will be

presumed to be true and correct to the best of the applicant’s ability. This will be presumed whether the

affidavit is signed and submitted through the mail or electronically within an e-mail or an attachment to

an e-mail.

My location at the time of this request for a duplicate credential is: ______________________

(State, Country, or Territory).

I am requesting the Coast Guard issue a duplicate of the following:

__ Merchant Mariner Credential (MMC)

__ Medical Certificate

My credential(s) was/were lost in the following manner:

Address you would like the duplicate(s) mailed to:

In submitting this request, I understand that I am acting under the authority of my credential(s)

consistent with Title 46 CFR Section 5.57(b). Any fraudulent action taken as part of this request for a

duplicate credential may subject me to the suspension or revocation of my credential.

I am affirming that all the information I provided is true and correct to the best of my knowledge. If the

Coast Guard determines I have submitted materially false information within this affidavit, the Coast

Guard may refer the matter to the U.S. Attorney for action under Title 18 U.S. Code Section 1001.

This statement does not need to be notarized and will be accepted “with like force and effect” as a sworn

statement if the applicant completes the following:

I declare under penalty of perjury under the laws of the United States of America, that the foregoing is

true and correct.

Printed Full Name: _____________________ Signature: _______________________

Phone Number: ___________ Date: _______ Mariner Reference # or last 4 of SSN: ________