ITQ Ownership Form

OMB Control No. 0648-0240 Expires: 01/31/2019

U .S. Department of Commerce NOAA/National Marine Fisheries Service 55 Great Republic Drive Gloucester, MA 01930-2298 Tel: (978) 282-8483

Surfclam / Ocean Quahog Individual Transferable Quota (ITQ) Ownership Form Fishing Year 2018

Section A – Permit Holder Information
1. ITQ Permit Number:
2. Name of ITQ Permit Holder:			3. Date of Birth (if person) or TIN (if business):
			4. State Registered In (if business):
5. Business Mailing Address: Street or PO Box			6. Telephone Number:
			7. Email address (optional):
City	State	Zip Code
8. Individual/Sole Proprietorship General Partnership Limited Partnership C Corporation S Corporation Limited Liability Company (LLC) Other (specify) ______________

Section B – Certification of Bank-Held Quota Share
Is the ITQ permit holder identified above a state or federally chartered bank or other lender, which is holding the ITQ quota share solely as collateral on a loan, and does not exert control over how the associated annual cage tags are used?  Yes  No	If ‘No’, please skip to Section C, and complete the rest of this form.
	If ‘Yes’, complete all fields in Section B, and sign below. You do not need to complete Sections C-F.
Name of Borrower:	Borrower’s ITQ Permit Number:
The borrower must maintain a valid ITQ permit and any transfer of quota share or cage tags must be to the borrower’s ITQ permit listed here.
Under penalty of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the permit holder and the information contained in Section A and Section B is true, correct, and complete to the best of my knowledge and belief. (18 U.S.C. § 1001)
Signature:		Date:
Printed Name:

Section C – Identification of Corporate Officers
If the permit holder is not an individual, provide the names of all corporate officers. If necessary, attach additional sheets of paper.
Name (Last, First, Middle Initial)	DOB	Mailing Address (Street or PO Box, City, State, Zip code)	Title
President/CEO Vice President Secretary Treasurer Director/Manager Partner Other ________________
President/CEO Vice President Secretary Treasurer Director/Manager Partner Other ________________
President/CEO Vice President Secretary Treasurer Director/Manager Partner Other ________________
President/CEO Vice President Secretary Treasurer Director/Manager Partner Other ________________
President/CEO Vice President Secretary Treasurer Director/Manager Partner Other ________________

Section D – Identification of Major Shareholders and Partners Part 1 – First Level
List all shareholders with a 10% or greater ownership interest in the permit holder. If you list a business entity as a shareholder, use Part 2 to identify the specific ownership of that business. If necessary, attach additional sheets of paper.
Name (Last, First, Middle Initial)	TIN or DOB	Mailing Address (Street or PO Box, City, State, Zip code)	% Interest Held
Total Ownership			%
Number of shareholders with less than 10% ownership interest

Section D – Identification of Major Shareholders and Partners Part 2 – Second Level
List owners of any business from Section D - Part 1 above, down to the level of individual persons who make up that business. If more than one business is listed, be clear which individuals belong to which business. If necessary, attach additional sheets of paper.
Name (Last, First, Middle Initial)		TIN or DOB	Mailing Address (Street or PO Box, City, State, Zip code)	% Interest Held
Business Name 1 from Part 1
Owners of Business 1
Total Ownership of Business 1				%
Business Name 2 from Part 1
Owners of Business 2
Total Ownership of Business 2				%
Business Name 3 from Part 1
Owners of Business 3
Total Ownership of Business 3				%

Section E – Identification of Family
If any of the individuals listed in Section D (Parts 1&2) has an immediate family member who has an ownership interest in any other surfclam or ocean quahog ITQ permit list those family members here. Immediate family is defined as: Father, mother, husband, wife, son, daughter, brother, sister, grandfather, grandmother, grandson, granddaughter, father-in-law, or mother-in-law. If necessary, attach additional sheets of paper.
Name (Last, First, Middle Initial)	DOB	Mailing Address (Street or PO Box, City, State, Zip code)	Relationship to Person in Section D (ex. son of John Smith)	ITQ Permit Number(s)

Section F – Certification
Under penalty of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the applicant and completed this form, and the information contained is true, correct, and complete to the best of my knowledge and belief. (18 U.S.C. § 1001)
Signature:	Date:
Print Name:

To avoid delay in processing, please include all information requested.

Paperwork Reduction Act Statement:

Public reporting burden for this collection of information is estimated to average 1 hour per response for new entrants, and is estimated to average 5 minutes when pre-filled for renewing entities, 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.

Permit holder name, address, phone, and permit information will be released via a NOAA Fisheries website. All other data submitted will be handled as confidential in accordance with section 402(b) of the Magnuson-Stevens Act and NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. 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 under the Magnuson-Stevens Fishery Conservation and Management Act, 16 U.S.C. 1801 et seq.

Purpose: In order to manage U.S. fisheries, the NOAA National Marine Fisheries Service (NMFS) requires the use of permits or registrations by participants in the United States. Information on NMFS permit applicants and renewing holders includes vessel owner contact information, date of birth, and vessel descriptive information. Permit holder information may be used as sampling frames for surveys, as part of Fishery Management Council (FMC) analysis to support FMC decisions.

Routine Uses: The Department will use this information to determine permit eligibility and to identify fishery participants. Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a), to be shared within NMFS offices, in order to coordinate monitoring and management of sustainability of fisheries and protected resources, as well as with the applicable State or Regional Marine Fisheries Commissions and International Organizations. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of Records Notice COMMERCE/NOAA-19, Permits and Registrations for the United States Federally Regulated Fisheries.

Disclosure: Furnishing this information is voluntary; however, failure to provide complete and accurate information will prevent the determination of eligibility for a permit.

Instructions

Surfclam / Ocean Quahog ITQ Ownership Form

This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address below to provide ownership information for individuals or businesses applying for or renewing a surfclam or ocean quahog individual transferable quota (ITQ) permit. Any individual or business applying for or renewing an ITQ permit must document those individual persons who have an ownership interest of 10 percent or greater.

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 following address:

NOAA’s National Marine Fisheries Service

Greater Atlantic Regional Fisheries Office

Attn: Permits

55 Great Republic Drive

Gloucester, MA 01930

SECTION A – Permit Holder Information:

• Field 1. Permit Number: If you are submitting an initial application for a surfclam or ocean quahog ITQ permit and do not have an ITQ permit number, leave this field blank. Otherwise, enter your ITQ permit number.

• Fields 2-3. Legal name of ITQ permit holder and TIN or DOB: Enter the name of the business entity or individual that holds the ITQ permit. If a business entity, list tax identification number (TIN). If an individual person, list date of birth (DOB) using the format mm/dd/yyyy.

• Field 4. State Registered In (if business): If a business entity, list the state where that entity was established and is currently recognized as active.

• Field 5. Business Mailing Address: Enter the business mailing address, including street or PO Box number, city, state, and zip code where correspondence should be sent. This information should match the information provided on the application or renewal form.

• Fields 6-7: Business Phone and Email: List the business telephone number, including area code; email is optional. This information should match the information provided on the application or renewal form.

• Field 8: Check the box that best describes the ITQ permit holder.

SECTION B – Certification of Bank Held Quota Share

Read the statement and indicate whether the ITQ permit holder is a state or Federal chartered bank, which is holding the ITQ quota share solely as collateral on a loan, and does not exert control over how the associated annual cage tags are used.

If the answer is ‘No’, please skip the rest of Section B and proceed to Section C.

If the answer is ‘Yes’, please complete the rest of Section B. Enter the name of the borrower and the borrower’s ITQ permit number. The borrower must have a valid ITQ permit and renew it each year. Permanent transfer of quota share or temporary transfer of cage tags must go to the borrower. The borrower may then transfer the quota share or cage tags as needed. Then sign, date, and print your name at the end of Section B. You are not required to fill out Sections C-F for this form to be considered complete.

SECTION C – Identification of Corporate Officers

If the permit holder is a business entity, please identify the corporate officers in Section C. Each officer should be identified by name, date of birth, mailing address, and by checking the appropriate box(es) for their position(s).

SECTION D – Identification of Shareholders and Partners

The intent of Section D (Parts 1 and 2) is to identify all of the individuals who control the business and their percent of ownership interest. Use as many pages as needed to list each entity down to the individual level. Please note that only ownership interest for shareholders with greater than or equal to 10% ownership interest in the business entity must be reported.

• Part 1 – First Level

Part 1 must be filled with the business entities or individuals listed in Section A. List the tax identification number (TIN) for business entities and the date of birth (DOB) for individuals. List the mailing address (if different than Section A), and the % ownership interest in the ITQ permit as listed in Section A. Please see examples below.

• Part 2 – Second Level

If Part 1 includes any business entities, Part 2 should be completed. For example, if Part 1 listed a business entity and an individual, only the business entity would need to be entered into Part 2. If the business entity is able to be listed to the individual level in Part 2, no further identification is needed. However, if Part 2 includes a business entity, you will need to list the ownership behind this entity. All business entities owning 10% or greater interest in the ITQ permit must be listed to the individual level. Please see examples below. Print additional pages and write in “third level”, “fourth level”, etc. if needed.

Example A: Two individuals

Part 1

Name	TIN/DOB	Mailing Address	% Held
Spisula, Sally	2/29/1970	14 Solidissima St Cape May, NJ 08204	60 %
Arctica, Alex	9/14/1930	42 Islandica Blvd New Bedford,MA 02740	40 %
Total Ownership =			100%
Number of shareholders with less than 10% ownership interest			0

Part 2

Name		TIN/DOB	Mailing Address	% Held
Business name 1 from Part 1 .
Owners of Business	Not Required
Total Ownership of Business 1 =				%

Example B: An individual and a business

Part 1

Name	TIN/DOB	Mailing Address	% Held
Spisula, Sally	02/29/1970	14 Solidissima St Cape May, NJ 08204	50%
Clam Dredge, Inc.	10-1234567	1 Shellfish Ln Cape May, NJ 08204	50%
Total Ownership =			100%
Number of shareholders with less than 10% ownership interest

Part 2

Name		TIN/DOB	Mailing Address	% Held
Business name 1 from Part 1 Clam Dredge, Inc.
Owners of Business	Arctica, Alex	9/14/ 1930	42 Islandica Blvd New Bedford,MA 02740	60%
	Mercenaria, Mike	11/27/ 1947	35 Quahog Ln Gloucester, MA 01930	25%
	Spisula, Sally	02/29/ 1970	14 Solidissima St Cape May, NJ 08204	15%
Total Ownership of Business 1 =				100%

Example C: Two businesses and a third owner that holds less than 10%

Part 1

Name	TIN/DOB	Mailing Address	% Held
Clam Dredge, Inc.	10-1234567	1 Shellfish Ln Cape May, NJ 08204	30%
Wicked Good Chowder, Co.	12-9876543	7 Wampum Way New Bedford, MA 02740	62%
Total Ownership =			92 %
Number of shareholders with less than 10% ownership interest			1

Part 2

Name			TIN/DOB	Mailing Address	% Held
Business name 1 from Part 1 Clam Dredge, Inc.
Owners of Business	Arctica, Alex		9/14/ 1930	42 Islandica Blvd New Bedford,MA 02740	60%
	Mercenaria, Mike		11/27/ 1947	35 Quahog Ln Gloucester, MA 01930	25%
	Spisula, Sally		02/29/ 1970	14 Solidissima St Cape May, NJ 08204	15%
Total Ownership of Business 1 =					100%
Business name 2 from Part 1 Wicked Good Chowder, Co.
Owners of Business		Mya, Megan	3/24/ 1962	16 Arenaria St Portland, ME 04101	60%
		Mercenaria, Mike	11/27/ 1947	35 Quahog Ln Gloucester, MA 01930	40%
Total Ownership of Business 2=					100%

SECTION E – Identification of Family

If any immediate family members of the individuals identified in Section D have an ownership interest in any other surfclam or ocean quahog ITQ permit, those family members need to be identified here. Immediate family is defined as: Father, mother, husband, wife, son, daughter, brother, sister, grandfather, grandmother, grandson, granddaughter, father-in-law, or mother-in-law. For example, if Sally Spisula from Example A above, has a brother who has an ownership interest in another ITQ permit, his name, DOB, address, “brother of Sally Spisula”, and the associated ITQ permit number should be listed here. If necessary, attach additional sheets of paper.

SECTION F – Certification

The applicant or authorized representative must sign and date the form. By signing and dating the form, the applicant or authorized representative certifies under penalty of perjury that all information set forth in the form is true, correct, and complete to the best of the applicant’s knowledge or belief. The form will not be considered without the authorized representative’s signature. NMFS may request that the authorized representative for a business entity include a copy of the corporate resolution or other document authorizing the individual to sign and certify on behalf of the business entity. (18 U.S.C. § 1001)

For questions, please call 978-282-8483

SC/OQ ITQ Ownership

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