Pacific Coast Groundfish Buyback Loan Fee Collection Rep

OMB Control No.: 0648-0376; Expiration Date: 08/31/2008

Pacific Coast Groundfish Buyback Loan Fee Collection Report
Fee Collector's Name
Mailing Address
City
State
Zip
Phone Number
State Buyer Code
Month and Year of Landings

Fee Rate (%) Gross Value ($)

FOR LANDINGS OF

Sub-account

Pacific Coast Groundfish
California coastal Dungeness crab

BBGS-001GF
BBGS-001CC

5.00
1.24

California pink shrimp

BBGS-001CS

5.00

Oregon coastal Dungeness crab
Oregon pink shrimp

BBGS-001OC
BBGS-001OS

0.55
4.70

Washington coastal Dungeness crab BBGS-001WC

0.16

Washington pink shrimp

1.50

BBGS-001WS

Fee Collected ($)

Total Fees ($)
Fee Adjustment

By checking this box I certify that this payment is an adjustment
for fees previously owed but not paid.

Instructions:
1. Complete the fee collector's name, address, telephone number, state buyer code (fish buyer/processor license
number), and month and year of landings (MM/200X).
2. Record the gross value and fee collected for each fishery. The fee collected equals the applicable fee rate multiplied
by the gross value of fish landed for each vessel trip.
3. Note that deliveries must occur within the same month. Use a separate report for a different month.
4. Check the fee adjustment box if this payment is for previously owed fees.
5. Use Pay.gov to remit fee collected or mail a check payable to: "NMFS Pacific Coast Groundfish Buyback Loan" in
the amount of the total fees collected to: P O Box 979059, St. Louis, MO 63197-9000.
Paperwork Reduction Act Statement:
Public reporting burden for this collection of information is estimated to average one hour per response,
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 Leo Erwin, Chief, Financial
Services Division, NMFS, MB5, 1315 East West Highway, Silver Spring, MD 20910.
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.