Mothership Permit Change of Vessel Registration Permit O

OMB Control No. 0648-0620, Expires on: xx/xx/xxxx

Mothership Permit Change of Vessel Registration, Permit Owner, or Vessel Owner Application Form Pacific Coast Groundfish Trawl Rationalization Program

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

This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address given above to apply for a change of vessel registration, permit owner or vessel owner for a mothership (MS) permit. To complete the application process, any Economic Data Collection surveys due from the MS permit applicant must be deemed complete by the NOAA/Northwest Fisheries Science Center. Please submit your current MS permit with the completed application form.

Section A - Action(s) Requested

Please check the box next to the action(s) requested, and complete the sections listed for each action.

Section B - Current Permit Information

List permit number, vessel name currently registered to the permit, and vessel registration number. List the permit owner name as given on the current permit, as well as the tax identification number (TIN) for business entities or date of birth (DOB) for individuals. Please provide the business mailing address, phone number, fax number and email address. The applicant or authorized representative must sign and date the form to certify 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 applicant or 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.

Section C - Change of Vessel Registered to Permit

If you are changing the vessel registered to the permit, please indicate the name and registration number of the current vessel on the left side of Section C, and list the name and registration number of the new vessel on the right side of Section C. List the length overall of both the current and new vessel. If the permit will not be registered to a vessel, indicate "unidentified" for the new vessel name.

Section D - New Permit Owner

List the new permit owner name, as well as the tax identification number (TIN) for business entities or date of birth (DOB) for individuals. Please provide the new permit owner's business mailing address, phone number, fax number and email address.

Section E - New Vessel Owner

List the new vessel owner name as given on the US Coast Guard Certificate of Documentation, as well as the tax identification number (TIN) for business entities or date of birth (DOB) for individuals. Please provide the new vessel owner's business mailing address, phone number, fax number and email address.

Supplemental Documentation

• Submit your current MS permit when you request any actions on this form.

• Submit the USCG certificate of documentation with any change of vessel registered to the MS permit or any change of vessel owner request.

OMB Control No. 0648-0620, Expires on: xx/xx/xxxx

Mothership Permit Change of Vessel Registration, Permit Owner, or Vessel Owner Application Form Pacific Coast Groundfish Trawl Rationalization Program

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

Section A - Action(s) Requested

Change of vessel registered to MS permit (Complete sections B, C & E)

Change of permit owner (Complete sections B & D)

Change of vessel owner (Complete sections B & E)

Section B - Current Permit Information
1. Permit Number MS	2. Name of Currently Registered Vessel			3. USCG Documentation Number
4. Current Permit Owner Name				5. TIN (if business) or DOB (if person)
6. Business Mailing Address Street or PO Box				7. Business Phone ( )
				8. Business Fax (optional) ( )
City		State	Zip Code	9. Business Email (optional)
Certification of Applicant
Under penalties 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 herein is true, correct, and complete to the best of my knowledge and belief.
Signature of Applicant or Authorized Representative				Date
Printed Name of Applicant or Authorized Representative

Section C - Change of Vessel Registered to Permit
CURRENT VESSEL	NEW VESSEL
1. Current Vessel Name	4. New Vessel Name
2. Current Vessel USCG Documentation Number	5. New Vessel USCG Documentation Number
3. Current Vessel Length Overall (in feet)	6. New Vessel Length Overall (in feet)

Section D - New Permit Owner
1. New Permit Owner Name			2. TIN (if business) or DOB (if person)
3. Business Mailing Address Street or PO Box			4. Business Phone ( )
			5. Business Fax (optional) ( )
City	State	Zip Code	6. Business Email (optional)
Are you eligible to own a documented vessel under the terms of 46 USC 12102 (a)?  YES  NO		Permit Sale Price (optional) $_____________________ (U.S. dollars)

Section E - New Vessel Owner
1. New Vessel Owner Name			2. TIN (if business) or DOB (if person)
3. Business Mailing Address Street or PO Box			4. Business Phone ( )
			5. Business Fax (optional) ( )
City	State	Zip Code	6. Business Email (optional)

WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR Part 904, a civil penalty up to $100,000 under 16 USC 1858, and/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001.

PRIVACY ACT STATEMENT: Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. TIN or DOB, business phone number, fax number, and email, applicant eligibility criteria and permit sale price are not released to the public. The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registrations for United States Federally Regulated Fisheries. An amended notice was published in the Federal Register on August 7, 2015 (80 FR 47457) and became effective on September 15, 2015 (80 FR 55327).

PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 0.58 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 suggestions for reducing this burden to NOAA/National Marine Fisheries Service, West Coast Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. 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.

Mothership Permit Change of Vessel Registration, Permit Owner or Vessel Owner Application Form - Page 4 of 4