Trawl at sea process exception form

OMB Control No. 0648-0611; Expires: 09/30/2012

Non Whiting At Sea Processing Exemption Application Pacific Coast Groundfish

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration N ational 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 postmarked, hand delivered or received by National Marine Fisheries Service (NMFS), Northwest Region, Fisheries Permits Office, by February 15, 2012. Late applications will NOT be accepted. Type or print legibly in ink and keep a copy of the completed application for your records. Be sure to attach supporting documentation to the application substantiating at-sea processing of non-whiting groundfish in the Shorebased IFQ fishery. Mail the completed application and supporting documents to the address listed above.

SECTION A - VESSEL/VESSEL OWNER

• Permit Number/Vessel Name/Vessel Registration Number: Please provide the trawl endorsed limited entry permit number registered to the vessel at the time it was processing at-sea, the name of the applicant’s vessel and vessel owner making this application and the vessel’s U.S. Coast Guard documentation or state vessel registration number.

•Vessel Owner Name(s): If the vessel owner consists of more than one entity or individual, enter the name of each owner as given on the U.S. Coast Guard 1270 (managing owner and all other owners).

• Date of Birth or Tax ID Number: Enter the vessel owner(s)’ date of birth or Taxpayer Identification Number(s) (if business entity). Note the Privacy Act Statement at the end of the application.

• Business Mailing Address: Enter the business mailing address, including street or PO Box number (not both), state and zip code, where correspondence regarding this application should be sent. If the applicant is consists of more than one entity and/or individual, enter the business mailing address of the group’s designated representative.

• Business Phone, Fax and Email: List the business telephone and fax numbers including the area codes and email address. Fax and email are not required.

SECTION B – ELIGIBILITY CRITERIA: Please indicate whether the vessel given in Section A processed at sea non-whiting groundfish in the Shorebased IFQ fishery prior to August 31, 2010 and landed that processed catch with a shorebased processor or buyer.

SECTION C - CERTIFICATION OF APPLICANT AND NOTARY: This section must be completed 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 applicant or 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 applicant’s or authorized agent’s

signature. The notary must also sign and date the certification statement, and affix their notary stamp or seal.

SUPPLEMENTAL DOCUMENTATION: The best evidence of processing groundfish at-sea includes: receipts of processed products from shorebased processors, buyers or exporters, accompanied by state fish ticket or landings receipts appropriate to the processed product. You may provide documentation showing purchase of processing equipment for use on the vessel, however this documentation alone is not sufficient evidence to qualify the vessel for the exemption.

OMB Control No. 0648-0611; Expires: 09/30/2012

Non Whiting At Sea Processing Exemption Application Pacific Coast Groundfish				UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration N ational 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 – Vessel and Vessel Owner
Permit Number:		Vessel Name:				Vessel Number:
Current Permit Owner						Tax Identification Number (if business)
Last	First				MI	Date of Birth
Business Mailing Address (Street or P.O. Box)						Business Phone Number ( )
City	State		Zip Code			Business Fax Number ( )

Section B –Eligibility Criteria
[Please respond to the question below]

Did the vessel given in Section A legally process at sea non-whiting groundfish in the Shorebased IFQ fishery prior to August 31, 2010 and landed that processed catch with a shorebased processor or buyer?

□ YES □ NO

Section C – Certification and Notary
Under penalties of perjury, I hereby declare that I, the undersigned, is authorized to sign this form on behalf of the applicant and completed this form, 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, 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 2.0 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 216-100, Protection of Confidential Fisheries Statistics. Phone number, fax, email, TIN, and DOB are not released to the public.