ITQ Ownership Form

OMB Control No. 0648-0240

U.S. Department of Commerce
NOAA/National Marine Fisheries Service
55 Great Republic Drive
Gloucester, MA 01930-2298
Tel: (978) 282-8483

Expires: 12/31/2015

Surfclam / Ocean Quahog
Individual Transferable Quota (ITQ)
Ownership Form
Fishing Year 2016

Section A – Permit Holder Information
1. ITQ Permit Number:
2. Name of ITQ Permit Holder:

3. Date of Birth (if person) or TIN (if business):
4. State Registered In (if business):

5. Business Mailing Address:

6. Telephone Number:

Street or PO Box

7. Email address (optional):
City

State

Zip Code

8. Individual/Sole Proprietorship General Partnership Limited Partnership C Corporation S Corporation
Limited Liability Company (LLC) Other (specify) ______________

Section B – Certification of Bank-Held Quota Share
Is the ITQ permit holder identified above a state or federally
chartered bank or other lender, which is holding the ITQ quota share
solely as collateral on a loan, and does not exert control over how
the associated annual cage tags are used?
 Yes
 No

If ‘No’, please skip to Section C, and complete the rest
of this form.

Name of Borrower:

Borrower’s ITQ Permit Number:

If ‘Yes’, complete all fields in Section B, and sign
below. You do not need to complete Sections C-F.

The borrower must maintain a valid ITQ permit and any transfer of quota share or cage tags must be to the borrower’s ITQ
permit listed here.
Under penalty of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the
permit holder and the information contained in Section A and Section B is true, correct, and complete to the best of my
knowledge and belief. (18 U.S.C. § 1001)
Signature:
Date:

Printed Name:

SC/OQ ITQ Ownership
Page 1 of 7

Section C – Identification of Corporate Officers
If the permit holder is not an individual, provide the names of all corporate officers.
If necessary, attach additional sheets of paper.
Name
(Last, First, Middle Initial)

DOB

Mailing Address
(Street or PO Box, City, State, Zip code)

Title

President/CEO Vice President Secretary Treasurer Director/Manager Partner Other ________________

President/CEO Vice President Secretary Treasurer Director/Manager Partner Other ________________

President/CEO Vice President Secretary Treasurer Director/Manager Partner Other ________________

President/CEO Vice President Secretary Treasurer Director/Manager Partner Other ________________

President/CEO Vice President Secretary Treasurer Director/Manager Partner Other ________________

Section D – Identification of Major Shareholders and Partners
Part 1 – First Level
List all shareholders with a 10% or greater ownership interest in the permit holder. If you list a business entity as a
shareholder, use Part 2 to identify the specific ownership of that business. If necessary, attach additional sheets of paper.
Name
(Last, First, Middle Initial)

TIN or DOB

Mailing Address
(Street or PO Box, City, State, Zip code)

Total Ownership
Number of shareholders with less than 10% ownership interest

SC/OQ ITQ Ownership
Page 2 of 7

% Interest
Held

%

Section D – Identification of Major Shareholders and Partners
Part 2 – Second Level
List owners of any business from Section D - Part 1 above, down to the level of individual persons who make up that business.
If more than one business is listed, be clear which individuals belong to which business.
If necessary, attach additional sheets of paper.
Name
(Last, First, Middle Initial)

TIN or DOB

Mailing Address
(Street or PO Box, City, State, Zip code)

% Interest
Held

Owners of Business 1

Business Name 1 from Part 1

Total Ownership of Business 1

%

Total Ownership of Business 2

%

Total Ownership of Business 3

%

Owners of Business 2

Business Name 2 from Part 1

Owners of Business 3

Business Name 3 from Part 1

SC/OQ ITQ Ownership
Page 3 of 7

Section E – Identification of Family
If any of the individuals listed in Section D (Parts 1&2) has an immediate family member who has an ownership interest in any
other surfclam or ocean quahog ITQ permit list those family members here. Immediate family is defined as: Father, mother,
husband, wife, son, daughter, brother, sister, grandfather, grandmother, grandson, granddaughter, father-in-law, or mother-inlaw. If necessary, attach additional sheets of paper.
Relationship to
Name
ITQ Permit
Mailing Address
DOB
Person
in Section D
(Last, First, Middle Initial)
Number(s)
(Street or PO Box, City, State, Zip code)
(ex. son of John Smith)

Section F – Certification
Under penalty of perjury, I hereby declare that I, the undersigned, am authorized to certify this application on behalf of the
applicant and completed this form, and the information contained is true, correct, and complete to the best of my knowledge
and belief. (18 U.S.C. § 1001)
Signature:
Date:

Print Name:

To avoid delay in processing, please include all information requested.

PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 1 hour per
response for new entrants, and is estimated to average 5 minutes when pre-filled for renewing entities, including the time for reviewing
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 suggestions for reducing this burden to the Assistant Regional
Administrator, Sustainable Fisheries Division, NOAA National Marine Fisheries Service, 55 Great Republic Drive, Gloucester, MA 01930.
Permit holder name, address, phone, and permit information will be released via a NOAA Fisheries website. All other data submitted will be
handled as confidential in accordance with section 402(b) of the Magnuson-Stevens Act and NOAA Administrative Order 216-100, Protection of
Confidential Fisheries Statistics. Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be
subjected 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.

SC/OQ ITQ Ownership
Page 4 of 7

Instructions
Surfclam / Ocean Quahog ITQ Ownership Form
This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address below
to provide ownership information for individuals or businesses applying for or renewing a surfclam or ocean quahog
individual transferable quota (ITQ) permit. Any individual or business applying for or renewing an ITQ permit must
document those individual persons who have an ownership interest of 10 percent or greater.
Please type or print legibly in ink. Attach additional sheets as necessary. Sign in ink, keep a copy for your records,
and mail the completed form to the following address:
NOAA’s National Marine Fisheries Service
Greater Atlantic Regional Fisheries Office
Attn: Permits
55 Great Republic Drive
Gloucester, MA 01930

SECTION A – Permit Holder Information:
•

Field 1. Permit Number: If you are submitting an initial application for a surfclam or ocean quahog ITQ
permit and do not have an ITQ permit number, leave this field blank. Otherwise, enter your ITQ permit
number.

•

Fields 2-3. Legal name of ITQ permit holder and TIN or DOB: Enter the name of the business entity or
individual that holds the ITQ permit. If a business entity, list tax identification number (TIN). If an individual
person, list date of birth (DOB) using the format mm/dd/yyyy.

•

Field 4. State Registered In (if business): If a business entity, list the state where that entity was established
and is currently recognized as active.

•

Field 5. Business Mailing Address: Enter the business mailing address, including street or PO Box number,
city, state, and zip code where correspondence should be sent. This information should match the
information provided on the application or renewal form.

•

Fields 6-7: Business Phone and Email: List the business telephone number, including area code; email is
optional. This information should match the information provided on the application or renewal form.

•

Field 8: Check the box that best describes the ITQ permit holder.

SECTION B – Certification of Bank Held Quota Share
Read the statement and indicate whether the ITQ permit holder is a state or Federal chartered bank, which is holding
the ITQ quota share solely as collateral on a loan, and does not exert control over how the associated annual cage
tags are used.
If the answer is ‘No’, please skip the rest of Section B and proceed to Section C.
If the answer is ‘Yes’, please complete the rest of Section B. Enter the name of the borrower and the borrower’s ITQ
permit number. The borrower must have a valid ITQ permit and renew it each year. Permanent transfer of quota
share or temporary transfer of cage tags must go to the borrower. The borrower may then transfer the quota share
or cage tags as needed. Then sign, date, and print your name at the end of Section B. You are not required to fill
out Sections C-F for this form to be considered complete.

SC/OQ ITQ Ownership
Page 5 of 7

SECTION C – Identification of Corporate Officers
If the permit holder is a business entity, please identify the corporate officers in Section C. Each officer should be
identified by name, date of birth, mailing address, and by checking the appropriate box(es) for their position(s).
SECTION D – Identification of Shareholders and Partners
The intent of Section D (Parts 1 and 2) is to identify all of the individuals who control the business and their percent
of ownership interest. Use as many pages as needed to list each entity down to the individual level. Please note
that only ownership interest for shareholders with greater than or equal to 10% ownership interest in the business
entity must be reported.
•

Part 1 – First Level
Part 1 must be filled with the business entities or individuals listed in Section A. List the tax identification
number (TIN) for business entities and the date of birth (DOB) for individuals. List the mailing address (if
different than Section A), and the % ownership interest in the ITQ permit as listed in Section A. Please see
examples below.

•

Part 2 – Second Level
If Part 1 includes any business entities, Part 2 should be completed. For example, if Part 1 listed a business
entity and an individual, only the business entity would need to be entered into Part 2. If the business entity
is able to be listed to the individual level in Part 2, no further identification is needed. However, if Part 2
includes a business entity, you will need to list the ownership behind this entity. All business entities owning
10% or greater interest in the ITQ permit must be listed to the individual level. Please see examples below.
Print additional pages and write in “third level”, “fourth level”, etc. if needed.

Example A: Two individuals
Part 2

Part 1
TIN/DOB

Mailing Address
14 Solidissima St
Cape May, NJ 08204
42 Islandica Blvd
New Bedford,MA 02740

% Held

Total Ownership =

100%

Number of shareholders with less than 10% ownership
interest

0

Spisula, Sally

2/29/1970

Arctica, Alex

9/14/1930

60 %

Name

TIN/DOB

Mailing Address

% Held

Business name 1 from Part 1

.

40 %
Owners of Business

Name

Total Ownership of Business 1 =

%

Example B: An individual and a business
Part 2

Part 1
TIN/DOB

Spisula, Sally

02/29/1970

Clam
Dredge, Inc.

10-1234567

Mailing Address
14 Solidissima St
Cape May, NJ 08204
1 Shellfish Ln
Cape May, NJ 08204

Total Ownership =
Number of shareholders with less than 10% ownership
interest

% Held
50%

Name

Mailing Address

% Held

Clam Dredge, Inc.
Arctica, Alex

50%

100%

TIN/DOB

Business name 1 from Part 1

Owners of Business

Name

Mercenaria,
Mike
Spisula, Sally

9/14/
1930
11/27/
1947
02/29/
1970

42 Islandica Blvd
New Bedford,MA 02740
35 Quahog Ln
Gloucester, MA 01930
14 Solidissima St
Cape May, NJ 08204

Total Ownership of Business 1 =

SC/OQ ITQ Ownership
Page 6 of 7

60%
25%
15%

100%

Example C: Two businesses and a third owner that holds less than 10%
Part 2

Part 1
TIN/DOB
10-1234567
12-9876543

Mailing Address
1 Shellfish Ln
Cape May, NJ 08204
7 Wampum Way
New Bedford, MA 02740

% Held
30%

Name

92 %

Number of shareholders with less than 10% ownership
interest

1

Mailing Address

% Held

Clam Dredge, Inc.
Arctica, Alex

62%

Total Ownership =

TIN/DOB

Business name 1 from Part 1

Owners of Business

Name
Clam
Dredge, Inc.
Wicked Good
Chowder, Co.

Mercenaria,
Mike
Spisula, Sally

9/14/
1930
11/27/
1947
02/29/
1970

42 Islandica Blvd
New Bedford,MA 02740
35 Quahog Ln
Gloucester, MA 01930
14 Solidissima St
Cape May, NJ 08204

Total Ownership of Business 1 =

60%
25%
15%

100%

Business name 2 from Part 1

Wicked Good
Chowder, Co.
Owners of Business

Mya, Megan
Mercenaria,
Mike

3/24/
1962
11/27/
1947

16 Arenaria St
Portland, ME 04101
35 Quahog Ln
Gloucester, MA 01930

Total Ownership of Business 2=

60%
40%

100%

SECTION E – Identification of Family
If any immediate family members of the individuals identified in Section D have an ownership interest in any other
surfclam or ocean quahog ITQ permit, those family members need to be identified here. Immediate family is defined
as: Father, mother, husband, wife, son, daughter, brother, sister, grandfather, grandmother, grandson,
granddaughter, father-in-law, or mother-in-law. For example, if Sally Spisula from Example A above, has a brother
who has an ownership interest in another ITQ permit, his name, DOB, address, “brother of Sally Spisula”, and the
associated ITQ permit number should be listed here. If necessary, attach additional sheets of paper.
SECTION F – Certification
The applicant or authorized representative must sign and date the form. By signing and dating the form, the
applicant or authorized representative certifies under penalty of perjury that all information set forth in the form is
true, correct, and complete to the best of the applicant’s knowledge or belief. The form will not be considered without
the authorized representative’s signature. NMFS may request that the authorized representative for a business
entity include a copy of the corporate resolution or other document authorizing the individual to sign and certify on
behalf of the business entity. (18 U.S.C. § 1001)

For questions, please call 978-282-8483

Annual SC/OQ ITQ Permit Application
Page 7 of 7