Tilefish IFQ allocation interest declaration form (owner

National Marine Fisheries Service / Northeast Regional Office

Tilefish IFQ Allocation Interest Declaration
Form
All persons and entities who have an interest in the Tilefish IFQ Allocation Permit that is the subject of this
application must list all the other Tilefish IFQ Allocation Permits in which they have an interest. Individuals
who have an interest in a Tilefish IFQ Allocation Permit are defined as and include, but are not limited to,
individuals, persons who are shareholders or officers in a corporation, persons who have formed a
partnership (general or limited), immediate family members of those who hold an interest, and any other
entities that have an interest in a Tilefish IFQ Allocation Permit. If a corporation, partnership, or LLC is
listed in Column A, shareholders/officers must be identified.

Section A – Individual Applying for a Tilefish IFQ Allocation Permit
Name, Address, and Phone # of Entity: __________________________________________________
_________________________________________________________________________________
Section B – Owners of Tilefish IFQ Allocation in Section A and any other Tilefish IFQ Allocation
owned.
Column A – Entire name of
the owner(s) of the IFQ
Allocation in Section A.
Include both corporation
names and names of
Shareholders/Officers.
Owner(s) Name

Other Tilefish IFQ Allocations owned Provide the name, and Tilefish IFQ
Allocation permit application number for the other Tilefish IFQ Allocations in which
the owner(s) of the tilefish IFQ Allocation in Column A has an interest.

Tilefish IFQ Allocation
Permit Application #

Tilefish IFQ Allocation
Permit Application #

Tilefish IFQ Allocation
Permit Application #

I, the undersigned, am the owner or legally authorized agent of the owner of the IFQ Allocation named in Section A above. I affirm, subject
to the penalties provided in 18 USC 1001, that all information that I have given in obtaining this permit is true and correct. Name

of

Applicant (print clearly)____________________________________ Signature of Applicant
_____________________________________ Date_____________
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 5 minutes per
declaration , 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 the Assistant Regional Administrator, Sustainable Fisheries Division, NOAA National Marine Fisheries Service, 55 Great Republic Drive,
Gloucester, MA 01930.
All data will be kept confidential. Notwithstanding 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.

OMB CONTROL NO: 0648-0590
Expiration Date: 10/31/2013