Pacific Coast Groundfish Trawl Limited Entry Permit Owne

OMB No. 0648-0203; Expires 09/30/2009

PACIFIC COAST GROUNDFISH
TRAWL LIMITED ENTRY
PERMIT OWNER/HOLDER:
IDENTIFICATION OF
OWNERSHIP INTEREST

U.S. Dept. of Commerce/NOAA
National Marine Fisheries Service
Fisheries Permit Office
7600 Sand Point Way NE, Bldg #1
Seattle, WA 98115
Phone: 206-526-4353/Fax: 206-526-4461

Permit Owner/Holder Name:
Business Address (street or PO Box):
State

City

Zip

BLOCK A - IDENTIFICATION OF PERMIT OWNER/HOLDER

1. Is this business a publicly held corporation?

[ ] Yes [ ] No

2. a. Is this a corporation?
b. Is this a partnership?
c. State registered? _______

[ ] Yes [ ] No
[ ] Yes [ ] No

3. Is this an estate that has been probated?
[ ] Yes [ ] No
If yes, on what date was probate finalized: __________________
BLOCK B - IDENTIFICATION OF SHAREHOLDERS, PARTNERS, JOINT VENTURERS, SUCCESSOR-IN-INTERESTS
NOTE: IF OWNERSHIP CONSISTS OF SEPARATE/ADDITIONAL CORPORATIONS OR PARTNERSHIPS THE INDIVIDUAL OWNERS OF THOSE ENTITIES AND THE PERCENTAGE OF
INTEREST THOSE INDIVIDUALS HOLD IN THEIR RESPECTIVECORPORATIONS OR PARTNERSHIPS MUST ALSO BE LISTED.

1. NAME (Print or Type)

Business Address (Street or PO
Box, City, State, Zip Code)
2.

3. Percent (%) of
Interest Held

TOTAL OWNERSHIP:

100 %

If the above section does not provide sufficient space to list all individuals, please list remaining individuals on separate sheet.
BLOCK C - CERTIFICATION
Under penalty of perjury, I declare that I have examined this form, and to the best of my knowledge and belief, the
information I have presented here is true, correct and complete.
1. Signature

2. Date

3. Printed Name

4. Title

5. Signature of Notary Public

6. Affix Notary Stamp or Seal Below

7. Commission Expires

Rev. 06/23/2005

OMB No.; Expires 04/30/2008

INSTRUCTIONS
Trawl Permit Owner/Holder: Identification of Ownership Interest

This form must be submitted by corporations, partnerships, and other non-individual entities who own or hold a trawl endorsed Pacific
Coast Groundfish limited entry permit under 50 CFR Part 660 Subpart G. Please type, or print legibly in ink; you
may photocopy and attach additional sheets as necessary. Please sign in ink, have your signature notarized, retain a copy for your
records, and mail the completed form to: NMFS Northwest Region, Fisheries Permit Office, 7600 Sand Point Way NE, Bldg. #1,
Seattle, WA 98115. For information, contact the Fisheries Permit Office at 206-526-4353.
GENERAL INFORMATION
The information requested herein is needed by NMFS and the Pacific Fishery Management Council to assess and characterize the
nature of ownership in the groundfish trawl fishery in order to develop appropriate policy for the trawl rationalization program.
SPECIFIC INSTRUCTIONS
BLOCK A - IDENTIFICATION OF PERMIT OWNER/HOLDER
1.

Indicate if the Permit owner/holder is a publicly held corporation. If yes, sign the certification in Block C and return the form
to NMFS.

2.

(a)
(b)
(c)

Indicate if this is a corporation.
Indicate if this is a partnership.
Indicate which state the business entity is registered in.

3.

If the non-individual trawl permit owner/holder is an estate and all estate matters with regard to the disposition of the assets,
including the permit have been finalized you must answer “YES”. Please provide the date the estate was settled.

BLOCK B - IDENTIFICATION OF MEMBERS
1.

List the names of members. If a member is itself a corporation, partnership, or other such entity, you must also list the
owners of that member at this time.

2.

Please provide the business address for the individual who has ownership interest in the named entity.

3.

Enter the percentage of ownership interest that each constituent member holds; for example, if there are three equal
owners, enter "33-1/3" for each. The total interest of all members should equal 100 percent.

BLOCK C - CERTIFICATION
1-3. Sign and date the application in the presence of Notary Public, and print your name.
4.

Authorized representatives must submit proof of authorization from permit owner and state title.

5-7. To be completed by a Notary Public, not the person submitting this application.

PUBLIC REPORTING BURDEN STATEMENT
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including
the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing the burden, to Assistant Regional
Administrator, Sustainable Fisheries Division, NOAA National Marine Fisheries Service, P.O. Box 21668, Juneau,
AK 99802.
ADDITIONAL INFORMATION
Before completing this form please note the following: 1) Not withstanding any other provision of law, no person is
required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of
information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays
a currently valid OMB Control Number; 2) This information is mandatory and is required to manage commercial
fishing efforts under 50 CFR part 679 and under section 402(a) of the Magnuson-Stevens Act (16 U.S.C. 1801,
et seq.); 3) Responses to this information request are confidential under section 402(b) of the Magnuson-Stevens Act (16 U.S.C.
1801, et seq.). They are also confidential under NOAA Administrative Order 216-100, which sets forth procedures to protect
confidentiality of fishery statistics.”