Reimbursement form

OMB Control No. 0648-0593

VESSEL REIMBURSEMENT FORM

Expiration Date: 11/30/2015

OBSERVER TRIP ID

OBSERVER NAME

VESSEL NAME

DATES OF TRIP

MEAL EXPENSES

TOTAL COST

$25/DAY X
CORPORATION / OWNER NAME

EIN or SSN

DATE

OFFICE USE ONLY

MAILING ADDRESS AND PHONE #

SIGNATURE

INVOICE CODE

TASK NUMBER

PLEASE FILL OUT ALL BLANKS (EXCLUDING INVOICE CODE AND TASK NUMBER) AND MAIL TO:
Michael Enzenauer
NOAA Fisheries
3500 Delwood Beach Road
Panama City, FL 32408
PAPERWORK REDUCTION ACT STATEMENT: The information provided on this form will be used to reimburse you for specific expenses during the observed trip identified on the form. That trip
was observed in order to collect information that is used in analyses that support the conservation and management of living marine resources and that are required under the Magnuson-Stevens Fishery
Conservation and Management Act (MSA), the Endangered Species Act (ESA), the Marine Mammal Protection Act (MMPA), the National Environmental Policy Act (NEPA), the Regulatory
Flexibility Act (RFA), Executive Order 12866 (EO 12866), and other applicable law. The public reporting burden for this form is estimated to average 10 minutes per response, including the time for
completing, reviewing, and transmitting the information on the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing the burden to: National Marine Fisheries Service, F/SF1, National Observer Program, 1315 East West Highway, Silver Spring, MD 20910. Providing the requested information is required to
have the Central Administrative Support Center (CASC) and United States Treasury process and pay the reimbursement. The information on this form will be kept confidential as required under Section
402(b) of the MSA (18 U.S.C. 1881a(b)) and regulations at 50 C.F.R. Part 600, Subpart E. Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be
subject 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. This is an approved information collection under OMB Control No. 0648-0593 through 11/30/2015.

11-2012