Sablefish Permit Hold Count Exemption Identification of

OMB Control No. 0648-0203 Expires on: XX/XX/20XX

SABLEFISH PERMIT HOLD COUNT EXEMPTION IDENTIFICATION OF OWNERSHIP INTEREST FORM PACIFIC COAST GROUNDFISH

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration National Marine Fisheries Service, West Coast Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.westcoast.fisheries.noaa.gov

INSTRUCTIONS

This form must be completed and submitted to the National Marine Fisheries Service (NMFS) at the address given above to provide ownership information for individuals or businesses applying for an exemption to the hold count for sablefish-endorsed limited entry permits. Ownership interest information will assist NMFS in determining whether a vessel owner meets the qualifying criteria to qualify for an exemption to the hold limit for limited entry sablefish permits. Any individual or business applying for this exemption must meet the qualifying criteria specified at §660.25(b)(3)(iv)(C).

Please type or print legibly in ink. Attach additional sheets as necessary. Sign in ink and please keep a copy for your records. Mail the completed form to the address listed above.

Section A –Vessel Owner Identification

• Field 1. Permit Number/Vessel Name/USCG or State Registered Vessel Number: If you are submitting an ownership interest form with an application for an exemption to the sablefish-endorsed limited entry permit hold limit, please list the permit number(s) for which you are seeking the hold exemption, the name of the vessel registered to the permit, and its U.S. Coast Guard or state registered vessel number.

• Fields 2-3. Legal Name of: Enter the name of the business entity or individual that owns the vessel. 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 the item(s) should be sent. This information should match the information provided on the application or renewal form.

• Fields 6-8. Business Phone/Fax/Email: List the business telephone and fax numbers, including area codes; fax number and email are optional.

Section B – Identification of Shareholders and Partners

The intent of Section B (Parts 1 and 2) is to identify all of the individuals who have ownership interest in the business and their percent of ownership interest. Use as many pages as needed to list each entity down to the individual level.

• Part 1 – first level

Part 1 must be filled with the business entities or individuals listed in Section A. List the 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 permit as listed in Section A. Please see examples below.

• Part 2 – second level

If Part 1 included 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 this ownership behind this entity. Please see examples below and print additional pages and write in “third level”, “fourth level”, etc. if needed.

Example A: jointly named owners, two individuals

Part 1

NAME	TIN/DOB	BUSINESS MAILING ADDRESS	% HELD
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%

Part 1

NAME	TIN/DOB	BUSINESS MAILING ADDRESS	% HELD
Blackcod, Joe A	05/15/1959	3 Dover Lane Astoria, OR 54321	50%
Longliners, Inc.	91-1234567	PO Box 70, Newport, OR 54123	50%
TOTAL OWNERSHIP =			100%

Part 2

Part 2

NAME		DOB	BUSINESS MAILING ADDRESS	% HELD
business name from Part 1
List individual names
TOTAL OWNERSHIP =				%

NAME		DOB	BUSINESS MAILING ADDRESS	% HELD
business name from Part 1 Longliners, Inc.
List individual names	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	3%
TOTAL OWNERSHIP of Business 1 =				100%

Example C: jointly named owners, two businesses

Part 1

Part 2

NAME	TIN/DOB	BUSINESS MAILING ADDRESS	% HELD
Longliners, Inc.	91-1234567	PO Box 70, Newport, OR 54123	30%
Big Boat, LLC	71-7654321	4 Ever Whiting Astoria, OR 54321	70%
TOTAL OWNERSHIP =			100%

NAME		DOB	BUSINESS MAILING ADDRESS	% HELD
business name from Part 1 Longliners, Inc.
List individual names	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 Big Boat, LLC
List individual names	Hake, Jim C	06/03/1950	4 Ever Whiting Astoria, OR 54321	331/3%
	Hake, Brenda K	08/30/1954	4 Ever Whiting Astoria, OR 54321	331/3%
	Hake, Jr., Jim C	11/23/1975	12 Ever Whiting Astoria, OR 54321	331/3%
TOTAL OWNERSHIP of Business 2 =				100%

Section C – Certification of Applicant

The applicant or authorized representative must sign and date, under penalty of perjury, that the information contained 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.

OMB Control No. 0648-0203, formerly 0648-0737. Expires on: 8/31/2022

SABLEFISH PERMIT HOLD COUNT IDENTIFICATION OF OWNERSHIP INTEREST FORM PACIFIC COAST GROUNDFISH TRAWL RATIONALIZATION PROGRAM

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration National Marine Fisheries Service, West Coast Region Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.westcoast.fisheries.noaa.gov

Section A –Vessel Owner Identification
1. Permit Number Vessel Name USCG or State Registered Vessel Number or
2. Legal Name of Vessel Owner			3. TIN (if business) or DOB (if person)
			4. State Registered In (if business)
5. Business Mailing Address Street or PO Box			6. Business Phone Number ( )
			7. Business Fax Number (optional) ( )
City	State	Zip Code	8. 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)	% INTEREST HELD

TOTAL OWNERSHIP =			%
Section B, continued – Identification of Shareholders and Partners Part 2 – Second Level NOTE: Owners of a business entity from Section B – 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)	TIN or DOB	BUSINESS MAILING ADDRESS (Street or PO Box, City, State, Zip Code)	% INTEREST HELD
Business Name 1 from Part 1
TOTAL OWNERSHIP OF BUSINESS 1 =			%
Business Name 2 from Part 1
TOTAL OWNERSHIP OF BUSINESS 2 =			%
Business Name 3 from Part 1

TOTAL OWNERSHIP OF BUSINESS 3 =			%

Section C – Certification of Applicant This section must be completed to certify that the individual(s) have satisfactorily identified themselves.
Under penalties 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 herein is true, correct, and complete to the best of my knowledge and belief.
Signature of Authorized Representative	Date
Printed Name of Authorized Representative
Date Commission Expires

WARNING STATEMENT: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR Part 904, a civil penalty up to $100,000 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: Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. TIN or DOB, business phone number, fax number, and email 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. The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registrations 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 10 minutes 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 suggestions for reducing this burden to NOAA/National Marine Fisheries Service, West Coast Region, Attn: Program Manager, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. 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.

Sablefish Permit Hold Count Identification of Ownership Interest Form - Page 1 of 6