Form DI Form 9012 DI Form 9012 Federal Subsistence Customary Trade Recordkeeping Form

Federal Subsistence Customary Trade Record Keeping Form
Description:
Applicant's Name (First, Middle Initial, Last)

OMB Control No. 1090-####
Expires: ##/##/20##

Season:
Date of Birth

Permit #

Mailing Address

Physical Address

City, State, Zip Code

Community of Primary Residence

AK Drivers License # or other acceptable ID

Telephone Number(s)

Date Permit Issued (mm/dd/yy)

Issuing Agent (Print)

Applicant's Signature

X

I certify that I am a rural resident as definedby 50 CFR 100.4 and 36 CFR 242.4. I have read and
understand the conditions on the permit and agree to comply with them and applicable
regulations as found in 43 CFR 51 and 36 CFR 242.

Household members designated to fish with this Permit (must be Federally-qualified subsistence users)
Name _________________________________ DOB _______________ Name _________________________________ DOB ______________
Name _________________________________ DOB _______________ Name _________________________________ DOB ______________
Name __________________________________ DOB_______________ Name __________________________________ DOB_______________

Federal Subsistence Fishing Permit # for Applicant: _________________________
Federal Subsistence Customary Trade Report
Date of Sale Buyers Name

Buyers Address

Check here if no sales took place

Report Due by:

Number of Total Fish:
Species

Fish

Fish Parts

Eggs

Dollar Amount

NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the Alaska National Interest Lands Conservation Act; 36 CFR 242 and 43 CFR 51.
Purpose: The applicant’s information will be used to contact the individual if there are any questions on the harvest reported in the effort to manage fish and wildlife resources for future seasons.
Routine Uses: The Federal Subsistence Board will use the provided information to make recommendations to the Secretaries of Interior and Agriculture for the appointment of members to the Federal Subsistence
Regional Advisory Councils. More information about routine uses can be found in the System of Records Notice, Permits System, FWS-21.
Disclosure: Providing the information is voluntary, but required to obtain or retain a benefit.
PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501, et seq.), the Office of Subsistence Management collects information necessary to make recommendations to the Secretaries of the Interior and
Agriculture for appointment of members to the Federal Subsistence Regional Advisory Councils. It is our policy not to use your name for any other purpose. Your response is voluntary, but is required to obtain or
retain a benefit. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid
OMB control number. OMB has approved this collection of information and assigned Control No. 1090-####.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 10 minutes for the application and permit, and 5 minutes for the report, 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 aspect of this collection of information,
including suggestions for reducing this burden, to the Departmental Information Collection Clearance Officer, 1849 C Street, NW Washington, DC 20240, or via email at [email protected]. Please do not send your
completed form to this address.

DI Form 9012 Rev. 09/2024

Permit Conditions:

Fold on this line (second) - After making the folds, tape this flap to the bottom of the letter, making sure that the return address is visible.

Fold on this line (first)

Return Address

NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES

BUSINESS REPLY MAIL

FIRST CLASS MAIL

PERMIT NO. 12874

ANCHORAGE AK

POSTAGE WILL BE PAID BY ADDRESSEE

Address

Post Office Bar Code