ID of ownership interest - pacific coast groundfish sabl

OMB Control No. 0648-0203
Expiration Date: 09/30/2009

IDENTIFICATION OF
OWNERSHIP INTEREST
Sablefish Endorsed
Pacific Coast Groundfish
Limited Entry Permit

UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service
Northwest Region , Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070
Phone (206) 526-4353

Fax (206) 526-4461

www.nwr.noaa.gov

INSTRUCTIONS
IMPORTANT! This application must be submitted by legally recognized corporations, partnerships and other business
entities who own or hold a sablefish-endorsed Pacific Coast Groundfish Limited Entry Permit. This form must be
submitted with your annual permit renewal (due by November 30) and with any transfer request when the
resulting sablefish endorsed permit will list a business entity as either the permit owner or vessel owner. A
sablefish endorsed limited entry permit that lists a business entity will not be renewed until such time that NMFS receives
an ownership interest form from each business entity given on the permit and a completed renewal form and payment.
Please type or print legibly in ink. Attach additional sheets as necessary. Sign in ink, have your signature notarized, keep
a copy for your records and mail the completed form to the address listed above.
The purpose of this form is to provide NMFS with information to determine the number of sablefish endorsed permits
owned or held by an individual exceed the limit (3 permits unless otherwise grandfathered) and to determine if any change
in ownership has occurred to corporations and partnerships since the control date. Note: A “partnership” is defined as
two or more individuals, partnerships, or corporations, or combinations thereof, who have ownership interest in a permit,
including married couples and legally recognized partnerships, such as limited partnerships (LP), general partnerships
(GP), and limited liability partnerships (LLP).
SECTION A - PERMIT OWNER/VESSEL OWNER IDENTIFICATION:
!
!
!
!

Permit Number/Vessel Name/Vessel Registration Number: List the permit number, the name of the vessel registered
to the permit and the U.S. Coast Guard documentation or state vessel registration number.
Name/TIN: Enter the name of the business entity that owns or holds the permit and its tax identification number
(TIN).
Business Mailing Address: Enter the business mailing address, including street or PO Box number, state, and zip
code, where the item(s) should be sent.
Business Phone, Fax and Email: List the business telephone and fax numbers including the area codes; the fax
number and email are optional.

SECTION B - IDENTIFICATIONS OF SHAREHOLDERS AND PARTNERS: List each individual shareholder or partner
name (Last, First, Middle Initial) and their business address. The date of birth is required for each individual. If the
shareholder/partner is a corporation/partnership, list the individual names of all shareholders/partners of that entity.
Please respond to the question at the end of the Section. Note the Privacy Act Statement at the end of the application.
NMFS may request further documentation as proof of corporate or partnership ownership.

SECTION C - CERTIFICATION OF APPLICANT AND NOTARY: The authorized agent must sign and date the
application in the presence of a notary to certify that the individual(s) signing the form have satisfactorily identified
themselves. By signing and dating the application, the authorized agent certifies that all information set forth in the
application is true, correct, and complete to the best of the applicant's knowledge and belief. The application will not be
considered without the authorized agent’s signature. The notary must sign and date this section, and affix notary stamp
or seal. Note: The authorized agent must include a copy of the corporate resolution or other authorizing document
allowing the authorized agent to sign and certify on behalf of the corporation or partnership.

PACIFIC COAST IDENTIFICATION OF OWNERSHIP APPLICATION - PAGE 1 of 3

OMB Control No. 0648-0203
Expiration Date: 09/30/2009

IDENTIFICATION OF
OWNERSHIP INTEREST
Sablefish Endorsed
Pacific Coast Groundfish
Limited Entry Permit

UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service
Northwest Region , Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070
Phone (206) 526-4353

Fax (206) 526-4461

www.nwr.noaa.gov

SECTION A - PERMIT OWNER/VESSEL OWNER IDENTIFICATION
Permit Number

Vessel Name

USCG Doc or State Registration Number

GF
Business Entity Name

Tax Identification Number (TIN)

Business Mailing Address

Business Phone

(

Street or PO Box

)

Business Fax (optional)

(
City

State

Zip Code

)

Business Email (optional)

SECTION B - IDENTIFICATION OF SHAREHOLDERS AND PARTNERS
If necessary, attach an additional sheet of paper with the information required below.
NAME
(Last, First, Middle Initial)

Date of Birth (mm/dd/yyyy)

Have any individuals been added to the corporation or partnership since November 1, 2000?

BUSINESS MAILING ADDRESS
(Street or PO Box, City, State, Zip Code)

“ Yes

PACIFIC COAST IDENTIFICATION OF OWNERSHIP APPLICATION - PAGE 2 OF 3

“ No

OMB Control No. 0648-0203
Expiration Date: 09/30/2009

SECTION C - CERTIFICATION OF APPLICANT AND NOTARY
This section must be completed by a notary to certify that the individual(s) have satisfactorily identified themselves.
Under penalties of perjury, I hereby declare that I, the undersigned, completed this application, and the information contained herein is true, correct,
and complete to the best of my knowledge and belief.
Signature of Authorized Representative

Date

Printed Name of Authorized Representative (NOTE: attach authorization)

Notary Public Signature

“ ATTEST

Affix Notary Stamp or Seal Here

Date Commission Expires

WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR 904, a civil
penalty of up to $100,000 under 16 USC 1858, and as a federal crime under 18 USC 1001.
PRIVACY ACT STATEMENT: Your date of birth and TIN are confidential and protected under the Privacy Act. Provision of your date of birth and TIN is
mandatory as part of this collection. The primary purpose for requiring the date of birth is to verify the identity of individuals/entities doing business with the
government to provide a unique identification for assistance to comply with the Debt Collection Improvement Act of 1996 (Public Law 104-134) and for
enforcement activities.
The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registrations for United States Federally Regulated
Fisheries. A notice was published in the Federal Register on April 17, 2008 (73 FR 20914) and became effective on June 11, 2008 (73 FR 33065).
PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 0.17 hours 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 NOAA/National
Marine Fisheries Service, Northwest Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115.
ADDITIONAL INFORMATION: Before completing this form, please note the following: 1) This information is collected to manage and conserve the Pacific Coast
Groundfish fishery and more specifically, to maintain accurate and current records on all permit owners, permit holders and vessels registered to participate in the
Pacific Coast Groundfish Limited Entry Program. This information will be used to formally document a request from the permit owner to make a change to a permit
and allow the Agency to review and verify that such a request is in compliance with existing regulations, to monitor and analyze changes in participation in Pacific
Groundfish fishery, accurately record changes to the listed permit owner, permit holder or vessel registered to the permit, and maintain accurate and current
address and contact information of permit owners and holders to allow the Agency to notify them of changes in the fishery regulations. 2) This collection of
information is mandatory and a change in registration of limited entry permits is required at 50 CFR Section 660.335 (b-i). 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 216100, which sets forth procedures to protect confidentiality of fishery statistics. These procedures have been implemented under the NMFS Operations Manual
entitled, “Data Security Handbook of the Northwest and Alaska Region, National Marine Fisheries Service”. Not withstanding any other provision of the 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.

PACIFIC COAST IDENTIFICATION OF OWNERSHIP APPLICATION – PAGE 3 of 3