Tilefish IFQ allocation interest declaration form

National Marine Fisheries Service / Northeast Regional Office

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Tilefish IFQ Allocation Interest Declaration
Form
All persons and entities who have an interest in the Tilefish IFQ Allocation Permit that is the subject of this
application must list all the other Tilefish IFQ Allocation Permits in which they have an interest. Individuals
who have an interest in a Tilefish IFQ Allocation Permit are defined as and include, but are not limited to,
individuals, persons who are shareholders or officers in a corporation, persons who have formed a
partnership (general or limited), immediate family members of those who hold an interest, and any other
entities that have an interest in a Tilefish IFQ Allocation Permit. If a corporation, partnership, or LLC is
listed in Column A, shareholders/officers must be identified.
Section A – Individual Applying for a Tilefish IFQ Allocation Permit
Name, Address, and Phone # of Entity: __________________________________________________
_________________________________________________________________________________
Section B – Owners of Tilefish IFQ Allocation in Section A and any other Tilefish IFQ Allocation
owned.
Column A – Entire name of
the owner(s) of the IFQ
Allocation in Section A.
Include both corporation
names and names of
Shareholders/Officers.
Owner(s) Name

Other Tilefish IFQ Allocations owned Provide the name, and Tilefish IFQ
Allocation permit application number for the other Tilefish IFQ Allocations in which
the owner(s) of the tilefish IFQ Allocation in Column A has an interest.

Tilefish IFQ Allocation
Permit Application #

Tilefish IFQ Allocation
Permit Application #

Tilefish IFQ Allocation
Permit Application #

I, the undersigned, am the owner or legally authorized agent of the owner of the IFQ Allocation named in Section A above. I affirm,
subject to the penalties provided in 18 USC 1001, that all information that I have given in obtaining this permit is true and correct.

Name of Applicant (print clearly): ____________________________________
Signature of Applicant: _____________________________________ Date: _____________
OMB Control No. 0648-xxxx
Expiration Date: mm/dd/2009