Trawl Identification of Ownership Interest

OMB Control No. 0648-0611; Expiration Date: 09/30/2014

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

INSTRUCTIONS
This form will provide the National Marine Fisheries Service (NMFS) with ownership information for individuals or
businesses applying for or renewing a Quota Share (QS) permit and account, an IFQ vessel account, a whiting
mothership (MS) permit, or a mothership catcher vessel (MS/CV) endorsed permit. Ownership interest information
will assist NMFS in determining compliance with accumulation limits associated with each of these permits or
control of quota pounds under the Trawl Rationalization Program. Any individual or business applying for or
renewing any of the above permits or endorsements must document those individual persons that have an
ownership interest in the amount of greater than or equal to 2 percent.
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/VESSEL OWNER IDENTIFICATION






Field 1. Permit Number: If you are
submitting an ownership interest form with a
renewal for a QS permit, mothership permit
or mothership catcher vessel endorsed
permit, list the permit number.
Field 2. Vessel Name/USCG or State
Registered Vessel Number: If you are
submitting an ownership interest form for a
vessel, please provide the name of the
vessel and its USCG or state registered
vessel number.
Fields 3-4. Name/TIN/DOB: Enter the name
of the business entity or individual that owns
the permit or vessel. If a business entity, list
tax identification number (TIN). If an

individual, list date of birth (DOB) using the
format mm/dd/yyyy.


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



Field 6. 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.



Field 7-9. Business Phone/Fax/Email: List
the business telephone and fax numbers,
including area codes; fax number and email
are optional.

SECTION B – IDENTIFICATION OF SHAREHOLDERS AND PARTNERS
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 must be filled with the business entities or individuals listed in Section A. List the TIN for business
entities and the date of birth (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, the
percent ownership interest held should equal 100%. If one business entity is listed, the percent
ownership interest held should equal 100%. If an individual and a business entity are listed, list the
percent of the individual and the percent of the business entity (see examples below).
TRAWL IDENTIFICATION OF OWNERSHIP FORM – PAGE 1 OF 6



Part 2 – second level
If the information from Part 1 includes both individual and business entities, Part 2 should be completed.
Part 2 should list 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 required to be listed
on this form. Information should be provided down to the individual level. If necessary, attach an
additional sheet of paper (see examples below).

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%

DOB

NAME

BUSINESS MAILING
ADDRESS

%
HELD

business name from Part 1

List individual names

BUSINESS MAILING
ADDRESS

NAME

TOTAL OWNERSHIP =

%

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

Part 1
TIN/DOB

BUSINESS MAILING
ADDRESS

%
HELD

BUSINESS
MAILING ADDRESS

%
HELD

business name from Part 1

Dragger,
Joe A

05/15/1959

3 Dover Lane
Astoria, OR 54321

50%

Trawlers,
Inc.

91-1234567

PO Box 70,
Newport, OR 54123

50%

TOTAL OWNERSHIP =

DOB

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 =

TRAWL IDENTIFICATION OF OWNERSHIP FORM – PAGE 2 OF 6

100%

Example C: jointly named owners on permit, two businesses

Part 1

Part 2
TIN/DOB

BUSINESS MAILING
ADDRESS

%
HELD

BUSINESS
MAILING ADDRESS

%
HELD

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 =

DOB

NAME

100%

Trawlers, Inc.

List individual names

NAME

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

33 %

Hake, Brenda K

08/30/1954

4 Ever Whiting
Astoria, OR 54321

33 %

Hake, Jr., Fred J

11/23/1975

12 Ever Whiting
Astoria, OR 54321

33 %

TOTAL OWNERSHIP of Business 2 =

SECTION C – SMALL BUSINESS CERTIFICATION
Read the criteria to determine if you are a small business according to the criteria listed. Check the appropriate
box, yes or no.
SECTION D - 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.

NMFS may request a copy of the corporate resolution or other authorizing document allowing the
authorized agent to sign and certify on behalf of the business entity.

TRAWL IDENTIFICATION OF OWNERSHIP FORM – PAGE 3 OF 6

1/3

1/3

1/3

100%

OMB Control No. 0648-0611; Expiration Date: 09/30/2014

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 OR VESSEL OWNER IDENTIFICATION
1. Permit Number

2. Vessel Name

USCG or State Registered Vessel Number

3. Permit or Vessel Owner Name

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

5. State Registered In, if business entity

6. Business Mailing Address

7. Business Phone

(

Street or PO Box

)

8. Business Fax (optional)

(
City

State

)

9. Business Email (optional)

Zip Code

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 =

TRAWL IDENTIFICATION OF OWNERSHIP FORM – PAGE 4 OF 6

% INTEREST
HELD

%

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

TRAWL IDENTIFICATION OF OWNERSHIP FORM – PAGE 5 OF 6

SECTION C – SMALL BUSINESS CERTIFICATION
Are you a small business according to the standards outlined below?

“ YES

“ NO

Small businesses. The Small Business Administration has established size criteria for all major
industry sectors in the US, including fish harvesting and fish processing businesses. A business
involved in fish harvesting is a small business if it is independently owned and operated and not
dominant in its field of operation (including its affiliates) and if it has combined annual receipts not in
excess of $4.0 million for all its affiliated operations worldwide. A seafood processor is a small
business if it is independently owned and operated, not dominant in its field of operation, and employs
500 or fewer persons on a full time, part time, temporary, or other basis, at all its affiliated operations
worldwide. A business involved in both the harvesting and processing of seafood products is a small
business if it meets the $4.0 million criterion for fish harvesting operations. A wholesale business
servicing the fishing industry is a small business if it employs 100 or fewer persons on a full time, part
time, temporary, or other basis, at all its affiliated operations worldwide. For marinas and charter/party
boats, a small business is one with annual receipts not in excess of $7.0 million.
Small organizations. The Regulatory Flexibility Act defines “small organizations” as any nonprofit
enterprise that is independently owned and operated and is not dominant in its field.
Small governmental jurisdictions. The Regulatory Flexibility Act defines small governmental
jurisdictions as governments of cities, counties, towns, townships, villages, school districts, or special
districts with populations of less than 50,000.
SECTION D– CERTIFICATION AND NOTARY
Under penalties of perjury, I hereby declare that I, the undersigned, am authorized to sign this form on behalf of the applicant and I 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 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.

TRAWL IDENTIFICATION OF OWNERSHIP FORM – PAGE 6 OF 6