Form NOAA 88-164 NOAA 88-164 Fisherman's Contingency Fund Claim Application

NOAA FORM 88-164
(12-82)

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

OMB APPROVED NO. 0648-0082

FISHERMEN’S CONTINGENCY FUND CLAIM APPLICATION
PROPERTY LOSS

CLAIMANT’S NAME
STREET ADRESS

SOCIAL SECURITY NUMBER

CITY , STATE, ZIP

VESSEL OWNER

VESSEL NAME AND COAST GUARD OR STATE REGISTRATION NUMBER

Expires 12-31-2011
PHONE
TAX ID NUMBER

VESSEL OPERATOR
OWNER/OPERATOR
AMOUNT CLAIMED
I AM CLAIMING THE FOLLOWING AMOUNTS FOR DAMAGE AND/OR LOSS

GEAR LOSS ……………………….

$

HOME PORT
GEAR DAMAGE …………………..
VESSEL TYPE
VESSEL LOSS OR DAMAGE …….
ECONOMIC LOSS ………………….

TONNAGE

FUEL …………………………………
LOCATIONAL COORDINATES OF OBSTRUCTION (Use Loran C or the next
best available method of position fixing.)

OTHER EXPENSES ………………..

TOTAL ………………………...
DID YOU FILE 15-DAY REPORT? (NOAA Form
DATE FILED
88-166)
NO
YES
IF OBSTRUCTION WAS DRAGGED, AT WHAT LOCATION WAS IT LEFT?
DID YOU RECOVER THE OBSTRUCTION?
NO
YES
If so, KEEP IT AS EVIDENCE.
DESCRIBE OBSTRUCTION OR, IF YOU DIDN’T SEE IT, ITS NATURE
WAS A SURFACE MARKER ATTACHED TO OR NEAR THE OBSTRUCTION?
YES
NO
DO YOU HAVE PHOTOS OF THE OBSTRUCTION OR DAMAGE?
NO
YES
If so, ATTACH TO CLAIM
WHY DO YOU BELIEVE THE OBSTRUCTION IS ASSOCIATED WITH OIL AND GAS ACTIVITIES ON THE FEDERAL OUTER CONTINENTAL SHELF RATHER THAN WITH
NATURAL CAUSES, OTHER OCEAN USERS, OR OIL AND GAS ACTIVITIES WITHIN STATE WATERS?

CIRCUMSTANCES OF DAMAGE OR LOSS
DATE OF INCIDENT

TIME OF DAY

WATER DEPTH

VISIBILITY

VESSEL’S SPEED

DIRECTION

ACTIVITY OF VESSEL (Explain the vessel’s activity at the time, how captain and crew responded, attempts made to retrieve gear, extent of damage, what
crew did after incident. For example, did vessel continue fishing or return to port? If it returned, why? How much time did the incident involve?

NAMES OF OTHER VESSELS IN THE VICINITY AT TIME OF INCIDENT

Each claim must contain statements from any material witnesses to the casualty. These may be from crew members or any other person who may have
relevant information to substantiate both the fact and the nature of the casualty. Statements should describe the basic circumstances under which the
casualty occurred and any knowledge as to the probable or known cause of the casualty.
NAMES AND ADDRESSES OF WITNESSES WHOSE STATEMENTS ARE ATTACHED. (List and check appropriate box.)
NAME

CREW MEMBER
ADDRESS
PHONE
OTHER
NAME
CREW MEMBER
ADDRESS
PHONE
OTHER
NAME
CREW MEMBER
ADDRESS
PHONE
OTHER
All claims for fishing vessel or gear casualties must include invoices, receipts, affidavits, cancelled checks, or other acceptable documentation showing proof of purchase of
each item claimed.

KIND OF PROOF OF PURCHASE ATTACHED

All claims must include an estimate or a receipt for the repair or replacement cost of each item claimed. The estimate or receipt must be from a commercial
source unless the gear is repaired or constructed by the applicant. In that case, an itemized list of repair or replacement costs may be submitted in place of
a receipt or an estimate from a commercial source.
KIND OF DOCUMENTATION OF REPAIR OR REPLACEMENT COSTS ATTACHED

CLAIM APPLICATION (Cont’d.)

Page 2

ECONOMIC LOSS CLAIMED
Provide the following data for the calculation of your claim for economic loss: The dates of the trip tickets for the three trips before that of
the casualty (or if these are not available, three trips closest in time to the casualty); the number of pounds of fish caught (or gear units deployed) on each trip; the number of hours spent fishing (or gear units hauled) on each trip; and the amount you received in payment for the
catch on each trip. Attach copies of the three trip tickets.
DATE OF TRIP TICKET
From
To
NO. POUNDS FISH CAUGHT
NO. DAYS SPENT FISHING
$ VALUE OF CATCH
1
2
3
TOTAL

$

AVERAGE
AVERAGE INCOME PER DAY

$

PROVIDE THE FOLLOWING DATA FOR THE COMPENSABLE PERIOD STARTING WITH THE DATE OF THE CASUALTY AND CONTINUING THROUGH THE
DATE OF COMPLETION OF REPAIR OR REPLACEMENT.
DATE OF
NO. POUNDS
DAYS SPENT
GROSS INCOME
TRIP TICKET
FISH CAUGHT
FISHING
$ VALUE OF CATCH
NO. DAYS LOST
LOSS FOR TRIP
From
To
(Date of Casualty)

1

$

$

$

2
3
4
5

TOTAL

$

6

AVERAGE

$

7

TOTAL CLAIMED FOR ECONOMIIC LOSS (50% of total gross income loss)

$

EXPLAIN YOUR METHOD AND FACTS IN DETERMINING THE AMOUNT YOU ARE CLAIMING FOR ECONOMIC LOSS FOR THE COMPENSABLE PERIOD
BETWEEN THE DATE OF THE CASUALTY AND THE DATE OF COMPLETION OF REPAIR OR REPLACEMENT.

Continued on last page.
FUEL (Complete this section if you are claiming for extra fuel consumed as a result of the incident.)
DOLLAR AMOUNT CLAIMED FOR EXTRA FUEL CONSUMPTION
NUMBER OF DAYS YOUR FISHING TRIPS USUALLY LAST
ON THE TRIP OF THE INCIDENT, HOW MANY HOURS OF RUNNING TIME
WERE USED TO GO FROM YOUR PORT TO FISHING SITE?

ON THE TRIP OF THE INCIDENT, HOW MANY HOURS OF RUNNING TIME
WERE USED TO GO FROM FISHING SITE BACK TO PORT?

HOW MANY EXTRA HOURS OF RUNNING TIME ARE YOU CLAIMING AS A
RESULT OF THE INCIDENT?

HOW MANY DAYS HAD YOU BEEN FISHING WHEN THE INCIDENT
OCCURRED?

HOW MANY GALLONS OF FUEL DOES YOUR VESSEL BURN PER HOUR
GOING TO AND FROM FISHING SITES?

WHAT PRICE PER GALLON (Receipts must be submitted) DID YOU PAY
FOR THE FUEL BURNED ON THE TRIP OF THE INCIDENT?

EXPLAIN HOW YOU CALCULATED THE AMOUNT YOU’RE CLAIMING FOR EXTRA FUEL CONSUMPTION

Continued on last page.
OTHER EXPENSES
List below any other expenses you have incurred as a result of the incident for which your claim is filed. Submit with your claim.
ITEM
AMOUNT

TOTAL
NOAA FORM 88-164 (12-82)

CLAIM APPLICATION (Cont’d.)
I,

, a U.S. citizen, am the

Page 3

OWNER
OPERATOR of the

(CLAIMANT’S NAME)

(VESSEL’S NAME)

and have read all of the foregoing statements and supporting documents relating to this claim, and to the best of my knowledge all statements and documents are true and correct.
SIGNATURE

DATE

CRIMINAL PENALTY FOR FRAUDULENT CLAIM. Any person who files a fraudulent claim is subject to criminal prosecution under 18
U.S.C. Section 284 and 1001, each of which, upon conviction, imposes a penalty of not more than a $10,000 fine and 5 years imprisonment, or both.
Privacy Act Statement
Section 3701 (c) of title 31, United States Code, authorizes collection of this information. This information is part an application for
benefits and is required to obtain those benefits. The primary use of social security numbers or taxpayer identification numbers is to
verify the identity of the applicant(s) and to allow preparations of IRS 1099s for claim payments as required pursuant to Section 6109 of
the Internal Revenue code.
______________________________________________________________________________________________________________________
Public reporting burden for this collection of information is estimated to average 5.04 hours per response, including the time for reviewing
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 suggestions for reducing this burden to National Marine
Fisheries Service, Financial Services Division, F/MB5, 1315 East West Hwy., Rm. 13301, Silver Spring, MD 20910.
Confidential name and address information will be released via a NOAA Fisheries website for informational purposes. All other data
submitted will be handled as confidential Fishery Statistics. Nothwithstanding any other provisions of the law, no person is required to
respond to, nor shall any person be subjected 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.
______________________________________________________________________________________________________________________
REMARKS AND ADDITIONAL INFORMATION

SURROGATION AGREEMENT

I,
, on behalf of individual/corporation, in consideration of the
Compensation received pursuant to the provisions of the Outer Continental Shelf Lands Act Amendments
of 1978, Title IV, from the United States of America, represented by the Secretary of Commerce, acting by
and through the Administrator for the National Oceanic and Atmospheric Administration (the “Secretary”)
on the date hereof, I do hereby subrogate, assign, transfer and set over to the Secretary and the
Secretary’s successors and assigns, any and all rights and remedies, sums of money now due or owing to
and nature, which I have had, or now have, or may have arising out of the loss, damage or destruction to
our fishing vessel or gear for which the compensation has been granted, I hereby appoint the Secretary,
the Secretary’s successors and assigns, myself true and lawful attorney and attorneys, with full power of
substitution and revocation, for me and in my name, or otherwise, but for the sole use benefit of the said
Secretary, the Secretary’s successors and assigns, to ask, demand, sue for the said claim or claims, or
any part thereof.
I agree to provide the Secretary with all available and relevant information concerning the
circumstances surrounding the events leading to the loss, damage or destruction for which the
aforementioned compensation has been received. We also undertake to furnish the Secretary with such
affidavits or declarations and to give such oral evidence as the Secretary may, in his/her discretion, deem
necessary for the lawful pursuit of any claim arising from the aforementioned subrogated rights.
In witness whereof, I have hereunto set my hand and seal on the date indicated below.

Date

NOAA FORM 88-164 (12-82)

Signature

CLAIM NUMBER

CLAIMED LOSSES
(Fishermen’s Contingency Fund Claim Application) (Cont’d.)
ITEM
NO.

Page 4

QUANTITY

SIZE

ITEM (Indicate material of construction.)

LOST,
DAMAGED, OR
DESTROYED

INSTRUCTIONS: List each item of gear for which this claim is filed. In
the appropriate spaces, indicate the quantity, size, and material of construction of each item; whether it was lost, damaged, or destroyed; its
date of purchase, purchase price, and replacement or repair cost. Do
not write in the “For Agency Use Only” columns.
DATE OF
PURCHASE

PURCHASE
PRICE

REPLACEMENT
COST

REPAIR
COST

FOR AGENCY USE ONLY

AMOUNT
ALLOWED

REMARKS

NOAA FORM 88-164
(12-82)

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

FISHERMEN’S CONTINGENCY FUND CLAIM APPLICATION

OMB APPROVED
NO.0648-0082
Expires 12-31-2011

________________________________________________________________________________________________________________

IN STR UCTIO N S TO CLAIM AN TS
I.GEN ER AL
am ounts are reasonable. You w illnotbe com pensated for these
fees ifthe claim is denied.
The Fisherm en’s Contingency Fund is authorized by Title IV of
the O uter ContinentalShelfLands ActAm endm ents of1978. Its
(c) O TH ER : You m ay claim for any other consequential
purpose is to com pensate com m ercialfisherm en for dam age or loss
dam age loss,(exceptpersonalinjury) incurred as a consequence
caused by obstructions associated w ith oiland gas activities on the
ofthe fishing gear dam age or loss.
O uter ContinentalShelf(O CS). The Program is adm inistered by the
N ationalM arine Fisheries Service,FinancialServices D ivision - F/SF2,
III. N EG LIGEN CE CLAIM AN T
1315 East-W estH w y.– Rm .13138,Silver Spring,M D 20910.
An aw ard w illbe reduced to the extentthatthe dam age or loss
PR ESU M PTIO N O F CAU SATION
w as caused by your negligence or fault. Basic grounds for finding
A claim antnegligentor atfaultare listed in the FCF R egulations.
A presum ption thatthe dam age or loss w as caused by item s assocN egligence ofthe ow ner or operator offishing gear w illaffect
ciated w ith oiland gas activities on the O CS is allow ed ifyou recrew m em ber aw ards to the sam e extentthatitaffects an aw ard to
portthe dam age or loss to the N ationalM arine Fisheries Service
the ow ner or operator.
w ithin 15 days after the date your vesselfirstreturn to port. If
allthe criteria ofa 15-day reportare fulfilled,you need notestabIV. IN SU R AN CE PR OCEED S
lish the nature ofthe dam age. Ifa com plete reportis notsubm itted w ithin the 15 day period,the presum ption w illnotbe allow ed
An aw ard w illbe reduced by the am ountofany com pensation you
and you w illhave to prove thatthe obstruction causing the dam age
are entitled to receive from insurance.
w as related to O CS oiland gas activities.
V. PEN ALTY FO R FALSE CLAIM S
FILIN G YO U R CLAIM
Any person w ho files a fraudulentclaim is subjectto prosecution
You m ustfile,in w riting,a com plete and accurate claim w ithin 90
under 18 U .S.C.sections 2187 and 1001,each ofw hich,upon
days after the date you firstdiscovered your dam age or loss. The
conviction,im poses a penalty ofnotm ore than $10,000 fine and
term “filed” m eans delivered in person,or m ailed (as determ ined by
5 years im prisonm ent,or both.
the date ofthe postm ark) to the Chief,FSD ,address above. The
Chief,FSD ,suggests thatclaim s be sentby registered or certified
VI. D OCUM EN TATIO N R EQ U IR ED
m ail,return receiptrequested so you w illhave a record ofreceipt
ofyour claim .
H ere is a checklistofdocum ents w hich m ustbe subm itted w ith
your claim :
FAILU RE TO M EET FILIN G R EQ U IR EM EN TS
(1) W ith your claim for actualdam age:
The Chief,FSD ,m ay rejectyour claim ,ifitdoes notm eetthe filing
requirem ents. Ifyour claim is rejected,the Chief,FSD ,w illgive
(a) Proofthatyou purchased the fishing gear dam aged or lost.
you w ritten notice ofthe reasons for rejection w ithin 30 days after
Subm itcopies ofthe bestevidence available,e.g.,sales receipts,
the date on w hich your claim w as filed. Ifyou don’trefile an acceptaffidavits,cancelled checks,or other evidence;and
able claim w ithin 30 days after the date ofthis w ritten notice,you
are noteligible for Fund com pensation unless there are extenuating
(b) R eceipts or estim ates show ing repair or replacem entcosts.
circum stances.
(i) Ifyou replace your gear or have itrepaired before filing
AG G R EG ATIN G CLAIM S
your claim ,subm ita copy ofthe item ized invoice or receiptfor
the replacem entofrepair cost. Ifyou usually repair or construct
Ifm ore than one com m ercialfisherm an suffers loss or dam age from
your ow n gear,you m ay subm ita detailed estim ate ofyour ow n
the sam e incident(for exam ple,w hen severalm em bers ofthe crew
repair or construction cost;include receipts for m aterials used.
lose incom e due to loss offishing tim e),their losses should be included in one claim and subm itted on their behalfby the ow ner or
(ii) Ifyou have notreplaced or had your gear repaired beoperator ofthe com m ercialfishing vesselinvolved.
fore you file your claim ,subm itone estim ate from a com m ercial
fishing gear repair or supply com pany ofthe presentreplacem ent
AM EN D M EN T TO CLAIM S
or repair (w hichever applies) costofthe dam aged or lostfishing
gear. (N O TE: The Chief,FinancialServices D ivision,m ay reYou m ay am end your claim any tim e before the Chief,FSD ,issues
quire the subm ission ofa second-source estim ate.)
a initialdeterm ination.
(2) W ith your claim for consequentialdam ages:
II. W H AT CAN BE CLAIM ED
(a) In the case ofclaim s for resulting econom ic loss,a stateYou m ay file for actualand consequentialdam ages as follow s:
m entofthe am ountclaim ed and the basis for thatam ountw ith
supporting docum entation as follow s:
(1) ActualD am age:
(i) Trip tickets for the three vesseltrips im m ediately before
(a) The lesser ofthe gear’s repair or replacem entcost,and
the trip during w hich the casualty w as discovered and for the
vesseltrip im m ediately follow ing the trip during w hich the casu(b) The reasonable replacem entcostfor lostfishing gear.
alty occurred.
(2) ConsequentialD am age:
(a) RESU LTIN G ECON OM IC LO SS: You m ay claim for gross in
com e loss resulting from tim e lostbecause ofnotbeing able to fish,
or having to reduce fishing effort,during the period before the dam aged or lostfishing gear is repaired or replaced and available for
use. This period m ustbe reasonable. Itbegins on the date ofthe
casualty and stops on the date the dam age could reasonably have
been rem edied by repair or replacem ent.
(b) ATTO R N EY,CPA,CON SU LTAN T FEES: You m ay claim for
reasonable fees paid to an attorney,CPA,or other consultantfor
the preparation ofyour claim . The Chief,FSD ,w illdeterm ine w hat

(ii) A statem entofthe am ountoftim e involved on each of
the vesseltrips (or ifthe casualty involves fixed gear,a statem ent
ofthe num ber ofgear units hauled on each ofthese vesseltrips.)
(iii) A statem entofthe am ountoftim e lostfrom fishing
because ofthe dam age or loss and a fullexplanation ofw hy this
tim e period is reasonable.
(b) Com pensation for resulting econom ic loss w illbe based on
50 percentofthe gross incom e lost,as estim ated by the Chief,
FSD ,as a resultofnotbeing able to fish;or having to fish ata
reduced levelofeffortduring the period before the dam aged or
lostfishing gear is repaired or replaced and available for use.
The period begins on the date ofthe casualty and stops on the

INST RU CT IO NS CO NT INUE O N NEXT PAG E.

INSTRUCTIONS (Cont.d)
date the dam age or loss could reasonably have been rem edied by
repair or replacem ent. Appropriate docum entation m ay consist
ofpurchase orders,bills oflading,or statem ents from com m ercial
repair or supply sources.
(3)In the case ofam ounts claim ed for other consequentialdam ages resulting from the casualty,the claim m ustinclude a full
description ofw hateach am ountrepresents w ith suitable docum entation.
(4)Photographs (ifavailable)ofthe obstruction and ofany dam age to your gear.
(5)The nam e and m ailing address (phone num ber ifavailable)of
each person,ifany,to w hom you have given oralor w ritten notice thatsuch person caused or m ay have caused the dam age or
loss,together w ith a copy ofany w ritten notice given each such
person and a statem entw hether each such person has paid or
w illpay you for any portion ofthe dam age or loss.
VII. NM FS PROCESSING OF CLAIM S
The NationalM arine Fisheries Service w illprocess your claim
and m aila w ritten initialdeterm ination to you w ithin 60 days of
the date itis com plete w ith regard to the inform ation required
for com pensation from the Fund. An initialdeterm ination w ill
state (i)ifthe claim is disapproved,the reason for disapproval,
or (ii)ifthe claim is approved,the am ountofcom pensation and
the basis on w hich am ountw as determ ined. Ifyou disagree w ith
the initialdeterm ination,you or any other interested person w ho
subm itted evidence relating to the initialdeterm ination,m ay requesta review ofthe initialdeterm ination. Your w ritten request
m ustbe postm arked w ithin 30 days ofthe date ofthe initialdeterm ination and m ustfully state your reason(s)for disagreem ent.
Ifno requestfor initialreview is subm itted w ithin 30 days,the
Initialdeterm ination w illbecom e a finaldeterm ination. Ifa petition for review ofan initialdeterm ination is tim ely filed,the
AssistantAdm inistrator,NM FS,or his designee w illconducta
review ofthe initialdeterm ination,and issue a finaldeterm ination w ithin 60 days after the day on w hich the requestfor review
ofthe initialdeterm ination w as received.
VIII. PAYM ENT OF AW ARD FOR CLAIM
(1) W hen an initialdeterm ination becom es finalthe Chief,FSD ,
shallim m ediately disburse the am ountaw arded ifyou:
(a)State in w riting thatyou w illnotpetition for review ofthe
initialdeterm ination;and
(b)Sign an agreem entto repay allor any partofthe am ountof
the aw ard if,the am ountofan aw ard should for any reason be
subsequently reduced.
Ifyou do notsubm itthe agreem ents specified above,the Chief,
FSD ,w illnotdisburse the am ountofyour aw ard untilexpiration
of30 days after the issuance ofthe initialdeterm ination.
IX. SUBROGATION
Upon paym entofa claim ,the Chief,FSD ,m ustobtain a subrogation agreem entsigned by you w hich:
(1) Assigns to the Fund your rights againstthird parties;and
(2) Provides thatyou w illassistthe Fund in any reasonable
w ay to pursue those rights.
NOTE: The agreem ents specified above (Settlem entand Subrogation)w illbe m ailed to you along w ith the InitialD eterm ination. Ifyou acceptthe InitialD eterm ination,the am ountof
your aw ard w illbe disbursed im m ediately upon receiptofthe
signed docum ents.