Shoreside Aid Prequalification Worksheet and Affidavit~1.doc

Commonwealth of Massachusetts

Division of Marine Fisheries

251 Causeway Street, Suite 400

Boston, Massachusetts 02114

(617) 626-1520 fax (617) 626-1509

SHORESIDE BUSINESS PRE-QUALIFICATION WORKSHEET & AFFIDAVIT

FOR GROUNDFISH DISASTER ECONOMIC ASSISTANCE APPLICATION

APPLICATION DEADLINE: May 31, 2015

Submit to MA DMF (c/o Samantha Andrews) by mail at 251 Causeway St., Suite 400, Boston, MA 02114, Accurate responses to the questions below will assist in evaluating pre-qualification for economic assistance from Phase 2 of the Commonwealth’s 2012 Groundfish Disaster Economic Assistance Program. Contact Samantha Andrews with any questions by email at Samantha.n.andrews@state.ma.us or by phone at (617.626.1564) Business Information

7. Is this business currently incorporated with a current physical place of business in the Commonwealth of Massachusetts?

YES ______

NO ______

8. Was this business incorporated with a physical place of business in the Commonwealth of Massachusetts in at least one year during Calendar Year (CY) 2009-2013? YES ______

NO ______

If yes, which years? (please check appropriate) 2009 ___ 2010 ___ 2011 ___ 2012 ___ 2013 ___

Relation to MA Commercial Groundfishery

9. Can you document at least 30% and at least $32,500 of your total business receipts/sales in any one year from Calendar Year 2009 – 2013 was generated from commercial vessels with limited access multispecies permits and/or state waters Groundfish Endorsements (GEs)? YES ______

NO ______

10. Was at least one of those commercial groundfish vessels qualified for 2012 Groundfish Disaster Aid (see enclosed list)?

YES ______

NO ______

If yes, please provide vessel name(s):________________________________________________________

11. If you answered yes to questions (7) – (10) above, please provide information on the next page regarding your commercial groundfish-related business receipts/sales for each calendar year as appropriate (no documentation is needed at this point, but may be required by DMF at a later date to fully qualify an applicant).

Business Receipts/Sales from Commercial Groundfish Fishery

12. Provide a brief narrative explaining how business is directly related to the commercial limited access groundfish industry impacted by the 2012 Groundfish Fishery Disaster. The explanation should include names of commercial limited access groundfish vessels with which you did direct business during any calendar year from 2009 thru 2013.

(Attach additional pages as necessary)

Signature & Affidavit

I, __________________________________, am the current legal owner and was the legal owner on

(Print Business Owner Name)

April 30, 2014 of _____________________________________________. The said business named in

(Print Name of Business) this Affidavit did service with the commercial limited access groundfishery impacted by the 2012 Groundfish Fishery Disaster during all or a portion of the calendar year period from 2009 thru 2013 and continues to service the commercial limited access groundfishery. I certify under the pains and penalties of perjury that all the information contained in this application is true and accurate to the best of my knowledge and belief, signed this ______ day of _____________, 2015 ____________________________.

(Signature of Affiant)

David E. Pierce

Acting Director

Charles D. Baker

Governor

Karyn E. Polito

Lieutenant Governor

Matthew A. Beaton

Secretary

George N. Peterson, Jr.

Commissioner

Mary-Lee King

Deputy Commissioner