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DEPARTMENT OF HOMELAND SECURITY U.S. Coast Guard BUILDER S CERTIFICATION AND FIRST TRANSFER OF TITLE OMB No 1625-0027 Expires 07/31/2019 I. PHASE OF CONSTRUCTION COVERED BY THIS CERTIFICATE YEAR PHASE OF CONSTRUCTION ENTIRE CONSTRUCTION HULL ONLY YEAR COMPLETED COMPLETION ONLY HULL BUILT BY ANOTHER II. VESSEL DATA A. HULL IDENTIFICATION NUMBER OR HULL NUMBER B. VESSEL NAME IF KNOWN C. EQUIPPED WITH ENGINE D. PLACE OF BUILD CITY STATE COUNTRY YES NO OUTBOARD E* HULL MATERIAL WOOD STEEL ALUMINUM FIBROUS REINFORCED PLASTIC CONCRETE OTHER III. DIMENSIONS COMPLETE APPROPRIATE DIAGRAM S - DIMENSIONS IN FEET AND TENTHS/INCHES DISTINCT KEEL FAIRED KEEL IV. UNITED STATES BUILD STATEMENT ALL MAJOR COMPONENTS USED IN THE PHASE OF CONSTRUCTION COVERED BY THIS CERTIFICATE WERE FABRICATED IN THE UNITED STATES* ALL CONSTRUCTION AND ALL ASSEMBLY FOR THIS PHASE OF CONSTRUCTION WERE DONE IN THE UNITED STATES* CG-1261 06/17 PREVIOUS EDITION OBSOLETE Page 1 of 2 Reset V. NAME S AND ADDRESS ES OF PARTY IES FOR WHOM BUILT IF BUILT FOR MORE THAN ONE PERSON THE PERSONS NAMED ABOVE ARE TENANTS IN COMMON EACH OWNING AN EQUAL UNDIVIDED INTEREST UNLESS OTHERWISE INDICATED HEREIN CHECK ONLY ONE OF THE FOLLOWING BLOCKS TO SHOW ANOTHER FORM OF OWNERSHIP. JOINT TENANCY WITH RIGHT OF SURVIVORSHIP COMMUNITY PROPERTY TENANCY BY THE ENTIRETIES OTHER Describe -- VI. CERTIFICATION I DO HEREBY CERTIFY THAT THE FACTS RECITED HEREIN ARE TRUE AND THAT I HAVE PERSONAL KNOWLEDGE OF THESE FACTS BECAUSE I PERSONALLY PERFORMED THE CONSTRUCTION OR SUPERVISED THE CONSTRUCTION AT AND ON BEHALF OF OR NAME OF COMPANY AM AN EMPLOYEE OF THE COMPANY WHO BUILT VESSEL AND HAVE EXAMINED THE RECORDS OF THE COMPANY CONCERNING THE FACTS OF BUILD OF THE VESSEL IN MY CAPACITY AS TITLE NOTE THIS CERTIFICATE MUST NOT BE COMPLETED BY AN IMPORTER OR AN IMPORTER S AGENT. SIGNATURE DATE VII. FIRST SALE OR TRANSFER OF VESSEL 100 OF THE VESSEL IDENTIFIED HEREIN IS SOLD TRANSFERRED BY THE PARTY IES NAMED IN SECTION V TO THE FOLLOWING PERSON S NAMES AND ADDRESSES IF SOLD TRANSFERRED TO MORE THAN ONE PERSON THE PURCHASER S TRANSFEREE S ARE TENANTS IN COMMON EACH OWNING AN EQUAL UNDIVIDED INTEREST UNLESS OTHERWISE INDICATED HEREIN CHECK ONLY ONE OF THE FOLLOWING BLOCKS TO SHOW ANOTHER FORM OF OWNERSHIP. VIII. SIGNATURES OF SELLER S TRANSFEROR S OR PERSONS SIGNING ON BEHALF OF SELLER S TRANSFEROR S DATE SIGNED IX. NAME S OR PERSON S SIGNING ABOVE AND LEGAL CAPACITY IN WHICH SIGNED E*G* OWNER AGENT TRUSTEE EXECUTOR X. ACKNOWLEDGEMENT TO BE COMPLETED BY NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED BY A LAW OF A STATE OR THE UNITED STATES TO TAKE OATHS* NAMED IN SECTION IX ABOVE ACKNOWLEDGED EXECUTION OF THE FOREGOING INSTRUMENT IN THEIR STATED CAPACITY IES FOR THE PURPOSES THEREIN CONTAINED. STATE COUNTY NOTARY PUBLIC MY COMMISSION EXPIRES PRIVACY ACT STATEMENT 1. AUTHORITY 46 U*S*C. CHAPTER 121 DOCUMENTATION OF VESSELS AND 46 CFR PART 67 DOCUMENTATION OF VESSELS* 2. PURPOSE TO PROVIDE BUILD INFORMATION DIMENSIONS AND PARTY FOR WHOM BUILT. 3. ROUTINE USES AUTHORIZED USCG PERSONNEL WILL USE THIS INFORMATION TO VALIDATE U*S* BUILD AND DETERMINE VESSEL MEETS THE FIVE NET TON REQUIREMENT FOR DOCUMENTATION* ANY DISCLOSURES OF DATA WITHIN THIS RECORD WILL BE MADE IN ACCORDANCE WITH DHS/USCG-013 MARINE INFORMATION FOR SAFETY AND LAW ENFORCEMENT MISLE 74 FEDERAL REGISTER FR 30305 JUNE 25 2009.