Reimbursement form

OMB Control No. 0648-xxxx

Expiration Date: xx/xx/2012

TRIP NUMBER

OBSERVER NAME

VESSEL NAME

INVOICE CODE

TASK NUMBER

DATES OF TRIP

MEAL EXPENSES

RATE DAYS AT SEA
$25/DAY X

SUBTOTAL

CORPORATION / OWNER NAME

TIN (Taxpayer Identification Number)

MAILING ADDRESS

PHONE

DATE

SIGNATURE

PAPERWORK REDUCTION ACT STATEMENT: The information provided on this form will be used to reimburse you for specific
expenses during the observed trip identified on the form. That trip was observed in order to collect information that is used in analyses that
support the conservation and management of living marine resources and that are required under the Magnuson-Stevens Fishery
Conservation and Management Act (MSA), the Endangered Species Act (ESA), the Marine Mammal Protection Act (MMPA), the National
Environmental Policy Act (NEPA), the Regulatory Flexibility Act (RFA), Executive Order 12866 (EO 12866), and other applicable law.
The public reporting burden for this form is estimated to average 10 minutes per response, including the time for completing, reviewing, and
transmitting the information on the form. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing the burden to: National Marine Fisheries Service, F/SF1, National Observer Program, 1315
East West Highway, Silver Spring, MD 20910. Providing the requested information is required to have the Central Administrative Support
Center (CASC) and United States Treasury process and pay the reimbursement. The information on this form will be kept confidential as
required under Section 402(b) of the MSA (18 U.S.C. 1881a(b)) and regulations at 50 C.F.R. Part 600, Subpart E. Notwithstanding any
other provision of the law, no person is required to respond to, nor shall any person be subject 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.