Vessel reimbursement form

OMB Control No: xxxx-xxxx
Expires on: mm/dd/yyyy

VESSEL REIMBURSEMENT FORM
(MULTI-DAY TRIPS ONLY)
TRIP ID # ____________________________
Subsistence Reimbursement form for Vessel Master on F/V ______________________________
for National Marine Fisheries Service observer ________________________________________
for period of deployment from _____________ to _____________ for a total of _________ days
at $25.00 per day for a total of $ ___________
________________________________________
Observer’s Signature

___________________
Date

________________________________________
Captain’s Signature

___________________
Date

Please make check payable to ______________________________________________________
Attn:

_________________________________________________________________

F/V

_________________________________________________________________

Street

_________________________________________________________________

City, State, Zip _________________________________________________________________
MAIL TO:

PROGRAM MANAGER
FISHERIES OBSERVER PROGRAM
166 WATER STREET
WOODS HOLE, MA 02543

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 3 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: Amy Van Atten, National Marine Fisheries
Service, Northeast Fisheries Science Center, Northeast Fisheries Observer Program, 166 Water Street, Woods Hole,
MA 02543-1026. Providing the requested information is needed in order to provide proper payment to the vessel. 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.