Schedule of Tax Basis

OMB No. 0648-0041

Expires: XX/XX/20XX

Case No.: CCF-______________________

Agreement holder Name: __________________________

Vessel Name: _­­­­­­­­_________________________

SCHEDULE OF TAX BASIS

ORIGINAL COST $

PLUS:

IMPROVEMENTS + $

LESS:

CCF WITHDRAWALS - $

LESS:

DEPRECIATION CLAIMED - $

REMAINING TAX BASIS * $

==========================

* Remaining tax basis should be as of the later of project completion date or last completed tax year. It should include the original cost plus all improvements to date less all CCF withdrawals to date less all depreciation claimed to date (if any).

Public Burden Statement

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0648-0041. Without this approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 1.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are required to obtain benefits. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the NOAA Fisheries, F/MB5, 1315 East West Hwy., Silver Spring, MD 20910, Attn: Richard VanGorder, and [email protected] if desired.

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.