CCF Application

OMB Control No. 0648-0041

Expiration Date: 3/31/2019

FISHING VESSEL CCF APPLICATION Date:

CCF Applicant Name:

Taxable Entity type: 0 Individual 0 C-Corporation 0 S-Corporation 0 Partnership

CCF application for the taxable year ending: (date)

TIN (Social Security or Employer Identification Number):

Estimated initial CCF deposit attributable to Schedule A vessel(s) from:

Fishing Income $ Sale/Insurance Proceeds $ , Depreciation $

Name and Address of each CCF depository (bank, brokerage, etc.) to be used:

The following checked items are attached as a part of this application: (Note: *Required **See instructions)

*NOAA Form 88-14, Interim Capital Construction Fund Agreement (2 signed forms)

*Completed Schedule A and Schedule B forms

**Evidence of ownership for all Schedule A eligible vessels to be a part of this CCF Agreement

**Evidence of lease for Schedule A vessel(s)

**Proof of U.S. citizenship (if Schedule A vessel leased, or 2 - 5 net tons)

**Evidence of debt for Schedule B vessel

*Federal tax return copies as filed with IRS for previous 2 years

**Signed and dated copy of IRS Automatic Extension notice, and copy of IRS approved Additional Extension Request, if applicable to this taxable year application

I hereby give permission to the administrators of my Capital Construction Fund Agreement to release and

obtain any information about the CCF Agreement from the following representative:

Representative (Name, Firm, etc.)

Address:

Phone ( ) FAX Phone ( )

Mail all CCF correspondence to: My Address My Representative Both

Applicant's Signature and Title

Address:

Phone ( ) FAX Phone ( )

Public reporting burden for this collection of information is estimated to average 1 hour per response, 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 NOAA Fisheries, F/MB5, 1315 East West Hwy., Silver Spring, MD 20910.

The information collected is confidential under the Magnuson-Stevens Fishery Conservation and Management Act, as amended in 2006, NOAA Administrative Order 216-100, which sets forth procedures to protect confidentiality of fishery statistics and 15CFR259.38(b).

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.

PRIVACY ACT STATEMENT

Authority: The collection of this information is authorized by Title 45 U.S.C 1177 and 50 CFR Part 259. The data will primarily be used for the evaluation of eligibility in connection with application to establish a Capital Construction Fund Account. Establishment of the account will not be considered unless all requested information is furnished.

Purpose: In order to determine qualification for, and to administer, the Capital Construction Fund, the NOAA National Marine Fisheries Service (NMFS) requires financial information, vessel owner contact information, date of birth, Tax Identifying Number and vessel descriptive information.

Routine Uses: The Department will use this information to determine qualification for a Capital Construction Fund Agreement. Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a), to be shared within the Financial Services Division, in order to coordinate monitoring of the Agreements. Disclosure of this information is also subject to all of the published routine uses as identified in Commerce/NOAA-21, Financial Services Division.

Disclosure: Furnishing this information is voluntary; however, failure to provide complete and accurate information will prevent the determination of qualification for the program, and continued participation.