Trawl Identification of ownership interest

OMB Control No. 0648-XXXX; Expires xx/xx/xxxx

TRAWL

IDENTIFICATION OF
OWNERSHIP INTEREST
PACIFIC COAST GROUNDFISH

UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service, Northwest Region
Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070
Phone (206) 526-4353

Fax (206) 526-4461

www.nwr.noaa.gov

INSTRUCTIONS
The purpose of this form is to provide NOAA Fisheries with baseline information on participants in the trawl
groundfish fishery to prepare for implementation of a future trawl rationalization program. Receipt of this form
does not guarantee that you will qualify for an initial allocation of quota share.
IMPORTANT! This form should be submitted by the following:
1) Current owners of each limited entry permit endorsed for trawl gear;
2) Current owners of each vessel registered to a limited entry permit endorsed for trawl gear
if not identical to the permit owner in number 1 above;
3) Current owners of Pacific whiting vessel licenses (if the vessel is not also associated with a
permit listed in numbers 1 or 2 above); and
4) First receivers issued Pacific whiting first receiver exempted fishing permits (EFPs) during the
2009 Pacific whiting shoreside fishery.
Pacific whiting shoreside first receivers means persons who receive, purchase, or take custody, control, or possession of
Pacific whiting onshore directly from a Pacific whiting shoreside vessel.

A form should be filled out for each permit, vessel, EFP, or whiting license for which you have an ownership
interest. Failure to complete this form may result in you not receiving an initial allocation of quota share. Please
type or print legibly in ink. Attach additional sheets as necessary. Sign in ink, have your signature notarized, keep
a copy for your records and mail the completed form to the address listed above.

SECTION A - PERMIT/VESSEL/PROCESSOR OWNER IDENTIFICATION
This section is pre-filled using information from NOAA Fisheries records. Please verify that the information
included is correct and make any necessary corrections by crossing out and filling in correct data on the form.
!

Field 1. Check all boxes that apply: If the
permit owner and vessel owner are identical,
check both boxes. If there are any differences
among the permit or vessel owners, then a new
form needs to be completed for each. If you are
a Pacific whiting shoreside first receiver, check
that box.

!

Fields 2-4. Permit Number/Vessel
Name/Vessel Registration Number: As
applicable, list the Federal groundfish limited
entry permit number, the name of the vessel
registered to the permit and the U.S. Coast
Guard documentation or state vessel registration
number.

!

Fields 5-6. Name/TIN/DOB: Enter the name of
the business entity or individual that owns the
permit, vessel, or first receiver. If a business
entity, list their tax identification number (TIN). If

an individual, list their date of birth (DOB) using
the format of mm/dd/yyyy.
!

Field 7. State Registered: If a business entity
is listed in Field 5, list the state where that entity
was established and is currently recognized as
active.

!

Field 8. Business Mailing Address: Enter the
business mailing address, including street or PO
Box number, state, and zip code, where the
item(s) should be sent. Also list a physical
address for first receivers, if different from
mailing address.

!

Fields 9-11. Business Phone, Fax and Email:
List the business telephone and fax numbers
including the area codes; the fax number and
email are optional.

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 1 of 7

OMB Control No. 0648-XXXX; Expires xx/xx/xxxx

SECTION B - IDENTIFICATION OF SHAREHOLDERS AND PARTNERS
This section is partially pre-filled using the business entity name(s) from Section A. The intent of Section B (Parts
1 and 2) is to identify all of the individuals who control the business and their percent of ownership interest. [Note:
Only shareholders with greater than or equal to 2% ownership interest in the business entity are required to report
their ownership interest.]
Part 1 – first level
Part 1 will be pre-filled with the business entities or individuals listed in Section A. List the TIN for
business entities and the DOB for individuals. List the mailing address (if different than Section A), and
the % ownership interest in the permit, vessel, or processor as listed in Section A. If there is only one
individual listed, then the percent ownership interest held should equal 100%. If one business entity is
listed, then the percent ownership interest held should equal 100%. If an individual and a business entity
are listed, then list the percent of the individual and the percent of the business entity. (see examples
below)
Part 2 – second level
If the information from Part 1 hasn’t gotten down to the individual level and still includes business entities,
then Part 2 should be completed. Part 2 will be pre-filled with any business entity names from Part 1.
List the individual names of all shareholders/partners of the business entity with greater than or equal to
2% ownership interest. The DOB is required for each individual as an additional means of identification.
List each individual’s business mailing address and the percent ownership interest they hold in the
business entity. The individual(s) listed under each business should equal 100%, except for cases where
some shareholders/partners in the business entity own less than 2% and are, therefore, not listed on this
form. Information should be provided down to the individual level. If necessary, attach an additional
sheet of paper. (see examples below).
Business entities established under the laws of the United States or any State must submit proof that they have
done so and to verify that they are an active corporation. NOAA Fisheries may request further documentation
as proof of ownership, including percentage of ownership. Note the Privacy Act Statement at the end of the

form.

Example A: jointly named owners on permit , two individuals

Part 1

Part 2
%
HELD

TIN/DOB

Ahab,
Captain R

05/15/1959

1234 Petrale St,
Astoria, OR 54321

75

Starbuck,
Jim T

10/23/1963

PO Box 555,
Newport, OR 54123

25

TOTAL OWNERSHIP =

100%

NAME

DOB

BUSINESS MAILING
ADDRESS

%
HELD

TOTAL OWNERSHIP =

100%

business name from Part 1

List individual names

BUSINESS MAILING
ADDRESS

NAME

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 2 of 7

OMB Control No. 0648-XXXX; Expires xx/xx/xxxx

Example B: jointly named owners on permit , an individual and a business

Part 1

Dragger,
Joe A
Trawlers,
Inc.

TIN/DOB

BUSINESS MAILING
ADDRESS

%
HELD

DOB

BUSINESS
MAILING ADDRESS

%
HELD

business name from Part 1

05/15/1959

3 Dover Lane
Astoria, OR 54321

50%

91-1234567

PO Box 70,
Newport, OR 54123

50%

TOTAL OWNERSHIP =

NAME

100%

Trawlers, Inc.

List individual names

NAME

Part 2

Ahab, Captain R

05/15/1959

1234 Petrale St,
Astoria, OR 54321

55%

Starbuck, Jim T

10/23/1963

PO Box 555,
Newport, OR 54123

30%

Ishmael, Mark S

03/07/1965

8 White Whale Dr.
Newport, OR 54123

10%

Queequeg,
Warren G

07/23/1968

13 Wildside Blvd.
Astoria, OR 54321

5%

TOTAL OWNERSHIP of Business 1 =

100%

BUSINESS
MAILING ADDRESS

%
HELD

Example C: jointly named owners on permit , two businesses

Part 1
TIN/DOB

BUSINESS MAILING
ADDRESS

%
HELD

DOB

business name from Part 1

Trawlers,
Inc.

91-1234567

PO Box 70,
Newport, OR 54123

30%

Big Boat,
LLC

71-7654321

4 Ever Whiting
Astoria, OR 54321

70%

TOTAL OWNERSHIP =

NAME

100%

Trawlers, Inc.

List individual names

NAME

Part 2

Ahab, Captain R

05/15/1959

1234 Petrale St,
Astoria, OR 54321

55%

Starbuck, Jim T

10/23/1963

PO Box 555,
Newport, OR 54123

30%

Ishmael, Mark S

03/07/1965

8 White Whale Dr.
Newport, OR 54123

10%

Queequeg,
Warren G

07/23/1968

13 Wildside Blvd.
Astoria, OR 54321

5%

TOTAL OWNERSHIP of Business 1 =

100%

business name from Part 1

List individual names

Big Boat, LLC
Hake, Fred C

06/03/1950

4 Ever Whiting
Astoria, OR 54321

33 %

Hake, Brenda K

08/30/1954

4 Ever Whiting
Astoria, OR 54321

33 %

Hake, Jr., Fred J

11/23/1975

12 Ever Whiting
Astoria, OR 54321

33 %

TOTAL OWNERSHIP of Business 2 =
WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 3 of 7

1/3

1/3

1/3

100%

OMB Control No. 0648-XXXX; Expires xx/xx/xxxx

SECTION C – SMALL BUSINESS CERTIFICATION
Read the criteria to determine if you are a small business according to the criteria listed. Check the appropriate
box, yes or no.

SECTION D - CERTIFICATION OF APPLICANT AND NOTARY
The authorized agent must sign and date the form in the presence of a notary to certify that the individual(s)
signing the form have satisfactorily identified themselves. By signing and dating the form, the authorized agent
certifies that all information set forth in the form is true, correct, and complete to the best of the applicant's
knowledge and belief. The form will not be considered without the authorized agent’s signature. If a single
individual is listed in Field 5 above, then that individual must sign. If two individuals are listed in Field 5 above,
then both individuals must sign. If an individual and a business entity are listed in Field 5 above, then the
individual and the authorized agent for the business entity must both sign.
The notary must sign and date this section, and affix notary stamp or seal.
The authorized agent must include a copy of the corporate resolution or other authorizing document
allowing the authorized agent to sign and certify on behalf of the business entity.

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 4 of 7

OMB Control No. 0648-XXXX; Expires xx/xx/xxxx

TRAWL

IDENTIFICATION OF
OWNERSHIP INTEREST
PACIFIC COAST GROUNDFISH

UNITED STATES DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric Administration
National Marine Fisheries Service, Northwest Region
Fisheries Permits Office
7600 Sand Point Way NE, Bldg. 1
Seattle, WA 98115-0070
Phone (206) 526-4353

Fax (206) 526-4461

www.nwr.noaa.gov

SECTION A – PERMIT/VESSEL/FIRST RECEIVER OWNER IDENTIFICATION

“ Permit Owner

1. Are you a:
2. Permit Number

“ Vessel Owner

“ Pacific Whiting First Receiver

3. Vessel Name

4. USCG Doc or State Registration Number

GF
5. Name

6. TIN or DOB

7. State Registered, if business entity

8. Business Mailing Address (also list physical address for first receiver, if different)

9. Business Phone

(

Street or PO Box

)

10. Business Fax (optional)

(
City

State

Zip Code

)

11. Business Email (optional)

SECTION B - IDENTIFICATION OF SHAREHOLDERS AND PARTNERS

PART 1 – first level
NAME
(Last, First, Middle Initial)

TIN or DOB

BUSINESS MAILING ADDRESS
(Street or PO Box, City, State, Zip Code)

TOTAL OWNERSHIP =

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 5 of 7

% INTEREST
HELD

100%

OMB Control No. 0648-XXXX; Expires xx/xx/xxxx

SECTION B - IDENTIFICATION OF SHAREHOLDERS AND PARTNERS

PART 2 – second level
NOTE: Owners of a business entity from Part 1 above must be listed down to the level of individual persons that make up that business.
If more than one business is listed, be clear which individuals belong to which business.
If necessary, attach an additional sheet of paper with the information required below.
NAME
(Last, First, Middle Initial)

DOB
(mm/dd/yyyy)

BUSINESS MAILING ADDRESS
(Street or PO Box, City, State, Zip Code)

% INTEREST
HELD
(IN BUSINESS)

list individual names

business name from Part 1

TOTAL OWNERSHIP of Business 1 =

100%

TOTAL OWNERSHIP of Business 2 =

100%

TOTAL OWNERSHIP of Business 3 =

100%

list individual names

business name from Part 1

list individual names

business name from Part 1

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 6 of 7

OMB Control No. 0648-XXXX; Expires xx/xx/xxxx

SECTION C – SMALL BUSINESS CERTIFICATION
Are you a small business according to the standards outlined below?

“ YES

“ NO

Small businesses. The Small Business Administration has established size criteria for all major
industry sectors in the US, including fish harvesting and fish processing businesses. A business
involved in fish harvesting is a small business if it is independently owned and operated and not
dominant in its field of operation (including its affiliates) and if it has combined annual receipts not in
excess of $4.0 million for all its affiliated operations worldwide. A seafood processor is a small
business if it is independently owned and operated, not dominant in its field of operation, and employs
500 or fewer persons on a full time, part time, temporary, or other basis, at all its affiliated operations
worldwide. A business involved in both the harvesting and processing of seafood products is a small
business if it meets the $4.0 million criterion for fish harvesting operations. A wholesale business
servicing the fishing industry is a small business if it employs 100 or fewer persons on a full time, part
time, temporary, or other basis, at all its affiliated operations worldwide. For marinas and charter/party
boats, a small business is one with annual receipts not in excess of $7.0 million.
Small organizations. The Regulatory Flexibility Act defines “small organizations” as any nonprofit
enterprise that is independently owned and operated and is not dominant in its field.
Small governmental jurisdictions. The Regulatory Flexibility Act defines small governmental
jurisdictions as governments of cities, counties, towns, townships, villages, school districts, or special
districts with populations of less than 50,000.

SECTION D - CERTIFICATION OF APPLICANT AND NOTARY
This section must be completed by a notary to certify that the individual(s) have satisfactorily identified themselves.
Under penalties of perjury, I hereby declare that I, the undersigned, completed this form, and the information contained herein is true, correct, and
complete to the best of my knowledge and belief.
Signature of Authorized Representative

Date

Printed Name of Authorized Representative (NOTE: attach authorization, if needed)

Notary Public Signature

“ ATTEST

Affix Notary Stamp or Seal Here

Date Commission Expires

WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR 904, a civil
penalty of up to $140,000 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: Your DOB and/or TIN are confidential and protected under the Privacy Act. Provision of your DOB or TIN is mandatory as part of
this collection. The primary purpose for requiring the DOB and/or TIN is to verify the identity of individuals/entities doing business with the government to provide a
unique identification for assistance to comply with the Debt Collection Improvement Act of 1996 (Public Law 104-134) and for enforcement activities. The
information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registration for United States Federally Regulated
Fisheries. A notice was published in the Federal Register on April 17, 2008 (73 FR 20914) and became effective on June 11, 2008 (73 FR 33065).
PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 0.5 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 aspect of this collection of information, including suggestions for reducing the burden, to NOAA/National
Marine Fisheries Service, Northwest Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115.
Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216100, Protection of Confidential Fisheries Statistics. Phone number, fax, email, TIN, and DOB are not released to the public. The names of individuals who have
an ownership interest in an entity that owns a permit, vessel or processing plant and the actual percentage of ownership are considered business confidential and
are not released to the public.

WEST COAST TRAWL IDENTIFICATION OF OWNERSHIP - PAGE 7 of 7