ID of ownership interest - pacific coast groundfish sabl

OMB Control No. 0648-0203; Expiration Date: 06/30/2013

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 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 and date the form and have your the form notarized.
Please 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 if the number of sablefish endorsed permits
owned or held by an individual exceeds the limit (3 permits unless otherwise grandfathered) and to determine if any
change in ownership has occurred with a corporation and partnership since the control date (November 1, 2000). A
change in a corporation/partnership is considered the addition of shareholder or member. Note: A “partnership” is defined
as two or more individuals, partnerships, or corporations, or combinations thereof, which 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:
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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 - IDENTIFICATIONOF 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 representative for the business entity
must sign and date the application in the presence of a notary to certify that the individual(s) signing the form have
satisfactorily identified themse to a notary . 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.

PACIFIC COAST IDENTIFICATION OF OWNERSHIP APPLICATION - PAGE 1 of 3

OMB Control No. 0648-0203; Expires

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

USCG Doc or State Registration Number

Vessel Name

GF

Business Entity Name

Tax Identification Number (TIN)

Business Mailing Address (Street or PO Box)

Business Phone

(

)

Business Fax (optional)

(

City

State

)

Business Email (optional)

Zip Code

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)

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

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

 Yes

PACIFIC COAST IDENTIFICATION OF OWNERSHIP APPLICATION - PAGE 2 OF 3

 No

OMB Control No. 0648-0203; Expires

SECTION C - CERTIFICATION OF APPLICANT AND NOTARY
This section must signed/dated by an authorized representative by the business entity in Section A and must be signed, dated and stamped
by a notary. . .
Under penalties of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the applicant ,completed this
application, 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)

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.
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.
Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act. It is also confidential under NOAA
Administrative Order 216-100, Protection of Confidential Fisheries Statistics. Phone number, fax and email information and TIN are not released to the public.
The permit sale/lease information and the amount of sablefish landed to date given on a transfer form are considered confidential. Similarly, the names associated
with a entity that owns a sablefish permit or has vessel registered to sablefish endorsed permit are confidential, as are date of birth for an individual and any
medical records provided to obtain an exemption from the owner on board required.
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).

PACIFIC COAST IDENTIFICATION OF OWNERSHIP APPLICATION – PAGE 3 of 3