Reimbursement for insurance expenses

NMFS/SEFSC/POP

OMB Control #0648-xxxx. Expires xx/xx/2012

REIMBURSEMENT INVOICE FOR CONTRACT OBSERVERS
VESSEL NAME

ORGANIZATION CODE

TRIP NUMBER

TASK NUMBER

DATES OF TRIP
TO

MEAL EXPENSES

RATE

DAYS AT SEA

$25 / DAY
RATE

SUBTOTAL

X
DAYS AT SEA

LIABILITY INSURANCE
*ATTACH ENDORSEMENT AND
BILLING STATEMENT
COMPANY NAME

AGENT NAME

PHONE
CORPORATION / OWNER NAME

TIN (Taxpayer Identification Number)

MAILING ADDRESS

PHONE

DATE

SIGNATURE

TOTAL

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.