Tilefish IFQ QS Interest Declaration Form

United States Department of Commerce
National Oceanic and Atmospheric Administration
National Marine Fisheries Service
Greater Atlantic Regional Fisheries Office
55 Great Republic Drive
Gloucester, MA 01930
OMB CONTROL NO.: 0648-0590
Expires: 11/30/2023

Tilefish IFQ Allocation Interest Declaration Form
All persons and entities who have an ownership interest in the Tilefish Individual
Transferable Quota (IFQ) Allocation Permit that is the subject of this form must list all
other Tilefish IFQ Allocation Permits in which they have an ownership interest.
Individuals who have an ownership interest in a Tilefish IFQ Allocation Permit are
defined as and include, but are not limited to, individuals, corporations, partnerships,
LLCs, persons who are shareholders or officers in a corporation, persons who have
formed a partnership (general or limited), immediate family members of those who hold
an ownership interest, and any other entities that have an ownership interest in a
Tilefish IFQ Allocation Permit. If a corporation, partnership, or LLC is listed in Section
B, shareholders/officers of that entity must also be identified.
Section A – Individual Applying for Tilefish IFQ Allocation Permit
Name, IFQ Permit Number, Address, and Phone #: ___________________________________

______________________________________________________________________
Section B –Tilefish IFQ Allocation Permit Holders Listed in Section A, and Any
other Tilefish IFQ Allocation held.
1. Interest in the Tilefish IFQ Allocation listed in Section A: If you listed a
corporation/partnership/LLC in Section A, list Shareholders, Partners, and Officers below. If you
listed a person in Section A, list all other persons that also have an ownership interest in this IFQ
allocation if they also have, or will apply for, another IFQ allocation permit.
2. Other Tilefish IFQ Allocations Held: Provide the Tilefish IFQ Allocation permit number(s) for any
other Tilefish IFQ Allocation the individual in the first column also has an ownership interest. Attach
additional sheets if necessary.
Name

IFQ Permit #

IFQ Permit #

IFQ Permit #

I, the undersigned, am the holder or legally authorized agent of the holder of the IFQ Allocation named in Section A above. I
affirm, subject to the penalties provided in 18 U.S.C. 1001, that all information that I have given in obtaining this permit is true and
correct.

Name of Applicant (print clearly) ______________________________________________________
Signature of Applicant _____________________________________________ Date_____________

Paperwork Reduction Act Statement
Public reporting burden for this collection of information is estimated to average 5 minutes per declaration, 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.
All data will be kept confidential. 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.
OMB CONTROL NO.: 0648-0590

Expires: 11/30/2023

Privacy Act Statement
Authority: The collection of this information is authorized under the Magnuson-Stevens Fishery Conservation and Management Act,
16 U.S.C. 1801 et seq.
Purpose: In order to manage U.S. fisheries, the NOAA National Marine Fisheries Service (NMFS) requires the use of permits or
registrations by participants in the United States. Information on NMFS permit applicants and renewing holders includes vessel
owner contact information and vessel descriptive information. Permit holder information may be used as sampling frames for
surveys, as part of Fishery Management Council (FMC) analysis to support FMC decisions.
Routine Uses: The Department will use this information to determine permit eligibility and to identify fishery participants. Disclosure
of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a), to be shared within NMFS offices, in order to
coordinate monitoring and management of sustainability of fisheries and protected resources, as well as with the applicable State or
Regional Marine Fisheries Commissions and International Organizations. Disclosure of this information is also subject to all of the
published routine uses as identified in the Privacy Act System of Records Notice COMMERCE/NOAA-19, Permits and Registrations
for the United States Federally Regulated Fisheries.
Disclosure: Furnishing this information is voluntary; however, failure to provide complete and accurate information will prevent the
determination of eligibility for a permit.