Department of Homeland Security, U.S. Coast Guard Oath for Qualification of a Not-For-Profit Oil Spill Response Cooperative [46 U.S.C. 12106(d)] Cooperative: Name Address Jurisdiction where incorporated or organized Affiant: Name Address Cooperative Title or Capacity

I, the affiant, swear that I am legally authorized to make this oath and hold the capacity so bestowed upon me as ________, on behalf of the ______________ cooperative and its members, that it is a not-for-profit cooperative, and that it is engaged in training for, carrying out, or supporting oil spill cleanup operations or related research activities.

That all members of the cooperative who may use the letter of qualification issued to this cooperative are truly and correctly named, including home address and citizenship of each on the attached listing incorporated in and made a part of this oath.

Signature Subscribed and sworn to before me on the day and year shown. (Notary Public) Date [CGD 90-055, 57 FR 7642, Mar. 3, 1992, as amended by USCG-2003-14505, 68 FR 9535, Feb. 28, 2003. Redesignated by USCG-2007-28098, 71 FR 61418, Oct. 18, 2006]