Trawl Identification fo Interest

OMB Control No. 0648-XXXX; Expiration Date: mm/dd/yyyy

TRAWL IDENTIFICATION
OF OWNERSHIP
INTEREST

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

PACIFIC COAST GROUNDFISH

INSTRUCTIONS
This form will provide NOAA Fisheries with information on owner of QS permit, MS permit, MS/CV endorsed
permit or vessel registered to a trawl limited entry permit for the purpose of determining compliance with
accumulation limits associated with each of these permits and associated quota share.
A form must be filled out for each permit you have an ownership interest at the time the above permits are
renewed and by new mothership or mothership/catcher vessel permit owners as part of transfer request or as part
of a QS permit application. Also, all owners of vessels who have a vessel account must submit a form to renew
the account. If a permit owner and the owner of the vessel registered to the permit are the same and the
ownership interest in both permit and vessel are identical, you need only complete one form. However
you must certify identical ownership interest in Field 4 (see below). 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.
SECTION A - PERMIT OWNER IDENTIFICATION
This section may be pre-filled using information from NOAA Fisheries records. If the form is not prefilled, you
must complete all sections. Please verify that the information included is correct and make any necessary
corrections by crossing out and filling in correct data on the form.
!

!

Field 1. Check all boxes that apply: An
Ownership interest form is required if you own
any of these permits or the vessels registered to
them.

!

Fields 5-6. Name/TIN/DOB: Enter the name of
the business entity or individual that owns the
permit. If a business entity, list their tax
identification number (TIN). If an individual, list
their date of birth (DOB) using the format of
mm/dd/yyyy.

!

Field 7. State Registered: If a business entity
is listed in Field 5, list the state where that entity
was established and is currently recognized as
active.

!

Field 8. 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. Also list a physical
address for first receivers, if different from
mailing address.

!

Fields 9-11. Business Phone, Fax and Email:
List the business telephone and fax numbers
including the area codes; the fax number and
email are optional.

Field 2. Permit Number: List the Federal
groundfish limited entry permit number or other
permit number as appropriate.
Field 3. Vessel Name/USCG Vessel Number:
If you are submitting an ownership interest form
for a vessel, please provide the name of the
vessel and its USCG vessel number.

!

Field 4. Certification: If the listed owner of the
permit and the owner of the vessel registered to
the permit are the same person and ownership
interest in both permit and vessel are identical
please, certify by checking YES. If the same
person owning both the permit and the
registered vessel are the same but have
different ownership interest (different
shareholders and/or ownership amounts) for the
permit and vessel, check NO and fill out
separate forms for the permit and vessel.

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 1 of 7

OMB Control No. 0648-XXXX; Expiration Date: mm/dd/yyyy

SECTION B - IDENTIFICATION OF SHAREHOLDERS AND PARTNERS
This section is partially pre-filled using the business entity name(s) from Section A. The intent of Section B (Parts
1 and 2) is to identify all of the individuals who control the business and their percent of ownership interest. [Note:
Only ownership interest for shareholders with greater than or equal to 2% ownership interest in the business
entity must be reported.]
Part 1 – first level
Part 1 will be pre-filled with the business entities or individuals listed in Section A. List the TIN for
business entities and the DOB for individuals. List the mailing address (if different than Section A), and
the % ownership interest in the permit as listed in Section A. If there is only one individual listed, then the
percent ownership interest held should equal 100%. If one business entity is listed, then the percent
ownership interest held should equal 100%. If an individual and a business entity are listed, then list the
percent of the individual and the percent of the business entity. (see examples below)
Part 2 – second level
If the information from Part 1 includes both individual and business entities, then Part 2 should be
completed. Part 2 will be pre-filled with any business entity names from Part 1. List the individual names
of all shareholders/partners of the business entity with greater than or equal to 2% ownership interest.
The DOB is required for each individual as an additional means of identification. List each individual’s
business mailing address and the percent ownership interest they hold in the business entity. The
individual(s) listed under each business should equal 100%, except for cases where some
shareholders/partners in the business entity own less than 2% and are, therefore, not listed on this form.
Information should be provided down to the individual level. If necessary, attach an additional sheet of
paper. (see examples below).
A business entity established under the laws of the United States or any State must submit proof that it is so
established and verify that it is an active corporation. NOAA Fisheries may request further documentation as
proof of ownership, including percentage of ownership. Note the Privacy Act Statement at the end of the

form.

Example A: jointly named owners on permit , two individuals

Part 1

Part 2
%
HELD

TIN/DOB

Ahab,
Captain R

05/15/1959

1234 Petrale St,
Astoria, OR 54321

75

Starbuck,
Jim T

10/23/1963

PO Box 555,
Newport, OR 54123

25

TOTAL OWNERSHIP =

100%

NAME

DOB

BUSINESS MAILING
ADDRESS

%
HELD

business name from Part 1

List individual names

BUSINESS MAILING
ADDRESS

NAME

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 2 of 7

TOTAL OWNERSHIP =

%

OMB Control No. 0648-XXXX; Expiration Date: mm/dd/yyyy

Example B: jointly named owners on permit, an individual and a business

Part 1

Dragger,
Joe A
Trawlers,
Inc.

TIN/DOB

BUSINESS MAILING
ADDRESS

%
HELD

DOB

BUSINESS
MAILING ADDRESS

%
HELD

business name from Part 1

05/15/1959

3 Dover Lane
Astoria, OR 54321

50%

91-1234567

PO Box 70,
Newport, OR 54123

50%

TOTAL OWNERSHIP =

NAME

100%

Trawlers, Inc.

List individual names

NAME

Part 2

Ahab, Captain R

05/15/1959

1234 Petrale St,
Astoria, OR 54321

55%

Starbuck, Jim T

10/23/1963

PO Box 555,
Newport, OR 54123

30%

Ishmael, Mark S

03/07/1965

8 White Whale Dr.
Newport, OR 54123

10%

Queequeg,
Warren G

07/23/1968

13 Wildside Blvd.
Astoria, OR 54321

3%

TOTAL OWNERSHIP of Business 1 =

100%

BUSINESS
MAILING ADDRESS

%
HELD

Example C: jointly named owners on permit, two businesses

Part 1
TIN/DOB

BUSINESS MAILING
ADDRESS

%
HELD

DOB

business name from Part 1

Trawlers,
Inc.

91-1234567

PO Box 70,
Newport, OR 54123

30%

Big Boat,
LLC

71-7654321

4 Ever Whiting
Astoria, OR 54321

70%

TOTAL OWNERSHIP =

NAME

100%

Trawlers, Inc.

List individual names

NAME

Part 2

Ahab, Captain R

05/15/1959

1234 Petrale St,
Astoria, OR 54321

55%

Starbuck, Jim T

10/23/1963

PO Box 555,
Newport, OR 54123

30%

Ishmael, Mark S

03/07/1965

8 White Whale Dr.
Newport, OR 54123

10%

Queequeg,
Warren G

07/23/1968

13 Wildside Blvd.
Astoria, OR 54321

5%

TOTAL OWNERSHIP of Business 1 =

100%

business name from Part 1

List individual names

Big Boat, LLC
Hake, Fred C

06/03/1950

4 Ever Whiting
Astoria, OR 54321

331/3%

Hake, Brenda K

08/30/1954

4 Ever Whiting
Astoria, OR 54321

331/3%

Hake, Jr., Fred J

11/23/1975

12 Ever Whiting
Astoria, OR 54321

331/3%

TOTAL OWNERSHIP of Business 2 =
WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 3 of 7

100%

OMB Control No. 0648-XXXX; Expiration Date: mm/dd/yyyy

SECTION C - CERTIFICATION OF APPLICANT AND NOTARY
The authorized agent must sign and date the form in the presence of a notary to certify that the individual(s)
signing the form have satisfactorily identified themselves. By signing and dating the form, the authorized agent
certifies that all information set forth in the form is true, correct, and complete to the best of the applicant's
knowledge and belief. The form will not be considered without the authorized agent’s signature. If a single
individual is listed in Field 5 above, then that individual must sign. If two individuals are listed in Field 5 above,
then both individuals must sign. If an individual and a business entity are listed in Field 5 above, then the
individual and the authorized agent for the business entity must both sign.
The notary must sign and date this section, and affix notary stamp or seal.
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 business entity.

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 4 of 7

OMB Control No. 0648-XXXX; Expiration Date: mm/dd/yyyy

TRAWL

IDENTIFICATION OF
OWNERSHIP INTEREST

PACIFIC COAST GROUNDFISH

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 IDENTIFICATION
1. Are you a:

 MS Permit Owner

 MS/CV endorsed permit owner

2.

3. Vessel Name:

 QS Permit Owner  Vessel Owner
USCG Vessel Number:

2. Permit Number:

4. If the same person(s) owns both the permit and vessel registered to it, please certify whether the ownership interests
(shareholders and percent of ownership) are identical in both:
[ ] Yes [ ] No If you check no, separate forms must be provided for each permit and/or vessel
5. Permit/Vessel Owner Name

6. TIN (if business) or DOB(if person)

7. State Registered, if business entity
8. Business Mailing Address (also list physical address for first receiver, if different)

9. Business Phone

(

Street or PO Box

)

10. Business Fax (optional)

(
City

State

Zip Code

)

11. Business Email (optional)

SECTION B - IDENTIFICATION OF SHAREHOLDERS AND PARTNERS

PART 1 – first level

NAME
(Last, First, Middle Initial)

TIN or DOB

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

TOTAL OWNERSHIP =
WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 5 of 7

% INTEREST
HELD

%

OMB Control No. 0648-XXXX; Expiration Date: mm/dd/yyyy

SECTION B - IDENTIFICATION OF SHAREHOLDERS AND PARTNERS

PART 2 – second level

NOTE: Owners of a business entity from Part 1 above must be listed down to the level of individual persons that make up that business.
If more than one business is listed, be clear which individuals belong to which business.
If necessary, attach an additional sheet of paper with the information required below.
NAME
(Last, First, Middle Initial)

DOB
(mm/dd/yyyy)

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

% INTEREST
HELD
(IN BUSINESS)

list individual names

business name from Part 1

TOTAL OWNERSHIP of Business 1 =

%

TOTAL OWNERSHIP of Business 2 =

%

TOTAL OWNERSHIP of Business 3 =

%

list individual names

business name from Part 1

list individual names

business name from Part 1

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 6 of 7

OMB Control No. 0648-XXXX; Expiration Date: mm/dd/yyyy

SECTION C – CERTIFICATION AND NOTARY
Under penalties of perjury, I hereby declare that I, the undersigned, completed this form, and the information contained herein is true, correct, and
complete to the best of my knowledge and belief.
Date

Signature of Authorized Representative

Printed Name of Authorized Representative (NOTE: attach authorization, if needed)

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 $140,000 under 16 USC 1858, and/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001.
PRIVACY ACT STATEMENT: Your DOB and/or TIN are confidential and protected under the Privacy Act. Provision of your DOB or TIN is mandatory as part of
this collection. The primary purpose for requiring the DOB and/or TIN 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 Registration 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 0.5 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.
Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216100, Protection of Confidential Fisheries Statistics. Phone number, fax, email, TIN, and DOB are not released to the public. The names of individuals who have
an ownership interest in an entity that owns a permit, vessel or processing plant and the actual percentage of ownership are considered business confidential and
are not released to the public.

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 7 of 7