Reimbursement for insurance expenses

NMFS/SEFSC/POP

OMB Control #0648-0593. Expires 09/30/2012

REIMBURSEMENT INVOICE FOR CONTRACT OBSERVERS
VESSEL NAME

TRIP NUMBER

ORGANIZATION CODE

DATES OF TRIP

TASK NUMBER

TO

RATE

DAYS AT SEA

MEAL EXPENSES
$25 / DAY
RATE

X

SUBTOTAL
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
toreimburse you for specific expenses during the observed trip identified on the form. That trip was observed in
orderto collect information that is used in analyses that support the conservation and management of living
marineresources and that are required under the Magnuson-Stevens Fishery Conservation and Management Act
(MSA), theEndangered Species Act (ESA), the Marine Mammal Protection Act (MMPA), the National
Environmental PolicyAct (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 forcompleting, reviewing, and transmitting the information on the form. Send comments
regarding this burden estimateor any other aspect of this collection of information, including suggestions for
reducing the burden to: NationalMarine Fisheries Service, F/SF1, National Observer Program,1315 East West
Highway,Silver Spring, MD20910.Providing the requested information is required to have the Central
Administrative Support Center (CASC) andUnited States Treasury process and pay the reimbursement. The
information on this form will be kept confidential asrequired under Section 402(b) of theMSA (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 subjectto a penalty for failure to comply with a collection of
information subject to the requirements of the PaperworkReduction Act, unless that collection of information
displays a currently valid OMB Control Number. This is anapproved information collection under OMB Control
No. 0648-0593 through 09/30/2012.