ID of ownership interest - pacific coast groundfish sabl

OMB Control No. 0648-0203; Expires 8/31/2016

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, West Coast Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.westcoast.fisheries.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 such time that 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 in ink, 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 the number of sablefish endorsed permits owned or held by an individual exceed the limit (3 permits unless otherwise grandfathered) and to determine if any change in ownership has occurred to corporations and partnerships since the control date. Note: A “partnership” is defined as two or more individuals, partnerships, or corporations, or combinations thereof, who 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:

1. 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.

2. Name/TIN: Enter the name of the business entity that owns or holds the permit and its tax identification number (TIN).

3. 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.

4. 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 - IDENTIFICATIONS OF 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: The applicant or an authorized representative must sign and date the application. 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.

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 West Coast 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 GF

Vessel Name

USCG Doc or State Registration Number

Business Entity Name			Tax Identification Number (TIN)
Business Mailing Address Street or PO Box			Business Phone ( )
			Business Fax (optional) ( )
City	State	Zip Code	Business Email (optional)

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  No

SECTION C - CERTIFICATION OF APPLICANT

Under penalties of perjury, I hereby declare that I, the undersigned, am authorized to complete and certify this application on behalf of the permit or vessel owner(s) 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

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 and list of shareholders are confidential and protected under the Privacy Act. Provision of your date of birth and TIN and names of shareholders is a 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. The list of shareholders is required to determine the number of permits owned or held by individuals.

PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 0.08 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).

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