National Marine Fisheries Service / Greater Atlantic Regional Fisheries 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 – Holders of Tilefish IFQ Allocation in Section A and any other Tilefish IFQ Allocation held. 

Column A – Entire name of the owner(s) of the IFQ Allocation in Section A. Include both corporation names and names of Shareholders/Officers. 	Other Tilefish IFQ Allocations held Provide the name, and Tilefish IFQ Allocation permit application number for the other Tilefish IFQ Allocations in which the holder(s) of the tilefish IFQ Allocation in Column A has an interest.  	
Holder(s) Name 	Tilefish IFQ Allocation  Permit Application # 	Tilefish IFQ Allocation  Permit Application #	Tilefish IFQ Allocation  Permit Application #	

				

				
I, the undersigned, am the holder or legally authorized agent of the holder 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
Expires:  10/31/2016