Form DI Form 9013 DI Form 9013 Designated Fishing Application, Permit, and Report

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

Federal Subsistence Designated Fishing Application

Permit No.

Federal Land Unit:

Federal Fish Management Area:

Applicant’s Name (First, Middle Initial, Last):

Date of Birth (mm/dd/yy):

Telephone Number:

Mailing Address:

Physical Address:

Community of Primary Residence:

Applicant’s Signature

Issuing Agent (Print):

X ____________________________________________________________________

Date Permit Issued (mm/dd/yy):

I certify that I am a rural resident as defined by 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.

Federal Subsistence Designated Permit Report

Report Due:

Permit Number:
Season:
Limit:

Did you or a household member use this Permit: Yes _____ No _____

Name

Permit Number

Permittee’s Name:

Location

Gear

Species

Number
Harvested

DI Form 9013 Rev. 09/2024

Conditions of the Permit:

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.

U.S. Department of the Interior
Office of Subsistence Management
1011 E. Tudor R. M/S 121
Anchorage, AK 99503-6199

NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES

OFFICIAL BUSINESS
PENALTY FOR PRIVATE USE $300

BUSINESS REPLY MAIL
FIRST-CLASS MAIL PERMIT NO. 12874 ANCHORAGE, AK
POSTAGE WILL BE PAID BY U.S. DEPARTMENT OF THE INTERIOR

U.S. DEPARTMENT OF THE INTERIOR

Conditions of the Permit:

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