Date: ___________________________ of _________________________________ of ____________________________ Sirs.
Fuel Control and Administration Section (Sección de Control y Administración del Combustible) Instituto Costarricense de Pesca y Acuicultura In accordance with the legal provisions on the matter, I request reimbursement for the following fuel:
Owner ________________________________________________________________ ID No. _________________________________ Vessel _______________________________________________________________ Registration No. _________________________________ Diesel _____________________________________________ Liters Gasoline ______________________________________________ Liters Days of absence _______________________________ between _______________________ and ____________________ Catch: Fish _________________________ Kg. - Shrimp ________________________ Kg. - Other __________________________ Kg.
Name of applicant _______________________________________________________ ID No. _________________________________ Registered Signature ____________________________________________________________________________________________________ _______________________________________________________________ FOR EXCLUSIVE USE OF THE DEPARTMENT OF CONTROL AND ADMINISTRATION OF FUEL Fishing period from ________________________________________ to ______________________________________ Diesel ( ) Gasoline ( ) Days of absence ___________________________________________ Multiplication factor _______________________________________ Authorized liters __________________________________________ Purchase Order No. _________________________________________ OBSERVATIONS:______________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ __________________________________________________________ Received by ____________________________
(Thus added by agreement AJDIP/119 of March 14, 2008)
No. ______________
I. GENERAL INFORMATION
Date: _______________________________________ Place of Sale: ___________________________________________________________ Vessel: _________________________________ Registration No.: ______________________________________________________________ Owner: __________________________________ ID: ________________________________________________________________ Captain's Name: ___________________________ ID: ________________________________________________________________ Buyer or Receiving Dock: _________________________________________________________________________________________ Fishing Gear: _________________________ Fishing Days: ________________________ Fishing Location: ___________________________
II. CATCH DETAIL
| COMMERCIAL GROUP | KILOS | PRICE | VALUE IN ¢ |
|---|
| GRAND TOTAL | | | |
III. OPERATING EXPENSES
| CONCEPT | TOTAL IN ¢ |
|---|
| FUEL | |
| LUBRICANTS | |
| ICE | |
| PROVISIONS | |
| BAIT | |
| OTHERS | |
| GRAND TOTAL | |
SIGNATURE OF THE FISHER: __________________________________________________________________
(Thus added by agreement AJDIP/119 of March 14, 2008)
(Small-Scale Artisanal Vessels) Sirs.
Fuel Control and Administration Section Instituto Costarricense de Pesca y Acuicultura The undersigned ______________________________________ bearer of identity card _____________ for the purpose of processing competitively priced fuel, under OATH and aware of the legal implications of false testimony, I proceed to provide the following detail of my fishing activities with the Vessel _________________ Registration No. _______, under the command of captain _____________________, bearer of identity card _________ during the period from _____________ to _____________.
| Day _________________________________________ departure time ______________________ arrival time ____________________ | | --- | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | | Day _________________________________________ departure time ______________________ arrival time ____________________ | BENEFICIARY SIGNATURE: _____________________________________________________________________
(Thus added by agreement AJDIP/119 of March 14, 2008)
Vessel: ______________________________________________ Registration No.: ___________________________________________ Owner's Name: _____________________________________ ID No.: ___________________________________________ Name of person withdrawing: ___________________________________ ID No.: ___________________________________________ Distributor's Name: _________________________________________________________________________________________ Distributor Seal | Purchase Order No. | Order Issue Date | Liters Authorized by INCOPESCA | Liters Withdrawn Station | Fuel Withdrawal Date | Pump Balance | Tank Balance | Signature of Beneficiary or Authorized Person | | --- | --- | --- | --- | --- | --- | --- | --- | _______________________________________ BENEFICIARY SIGNATURE
(Thus added by agreement AJDIP/119 of March 14, 2008)
Date: ______ / ______ / 20 _____. Office: _____________________________ Vessel Name: ____________________________________________________ Registration No.: _______________________________ Base of Operation: _________________________________________________________________________________________________ Owner: ____________________________________________________________ ID No.: __________________________________ | Last Purchase Order No. | Order Issue Date | Liters Authorized by INCOPESCA | Balance(s) recorded | Last Fishing Period Accounted (Departure and Arrival) | Contract Expiration Date | | --- | --- | --- | --- | --- | --- | (Signature Registration Card is attached) | Certificate of Seaworthiness Expiration Date | Fishing License Expiration Date | Annual Payment Expiration Date | | --- | --- | --- | (Fishing license and proof of income are attached) Observations:______________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ _______ Name of Officer: ___________________________________________________________ Signature of Officer: ______________________________________ Date: ___ / ___ / 20 ___ SEAL
(Thus added by agreement AJDIP/119 of March 14, 2008)
FOR RETURN OF INCOMPLETE DOCUMENTS FOR THE PROCESSING OF COMPETITIVELY PRICED FUEL.
INDIVIDUAL TRANSACTION VESSEL _________________________________ REGISTRATION NO. _____________________________ FILE NO. ___________________________ MARK WITH AN X ( ) 1. Complete fuel application.
( ) 2. Previous Order.
( ) 3. Original departure clearance (zarpe).
( ) 4. Photocopy of the logbook reporting the fishing zone.
( ) 5. Sworn declaration of the fishing trip.
( ) 6. Fuel purchase invoice (original and copy).
( ) 7. Product sale invoice (two copies and original).
( ) 8. Certification of Product Catch (Constancia de Captura del Producto).
( ) 9. Photocopy of the Balance Control Slip (sealed and signed).
( ) 10. Registration and up-to-date in the CCSS Contributory Scheme.
( ) 11. Contract validity and provision of the respective documents.
( ) 12. Validity of the fishing permit.
( ) 13. Others _____________________________________________________ OBSERVATIONS_______________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ _________________________________________________________ You are informed that you have a period of 10 business days in accordance with Law No. 8220 to resubmit the corresponding application properly.
Received by user ________________________________________ Date _______________________________________ Officer's Seal and Signature
(Thus added by agreement AJDIP/119 of March 14, 2008)
FOR RETURN OF INCOMPLETE DOCUMENTS FOR THE PROCESSING OF COMPETITIVELY PRICED FUEL.
FISHER ORGANIZATIONS
| Vessels | Registration No. | Vessels | Registration No. |
|---|
MARK WITH AN X ( ) 1. Complete fuel application.
( ) 2. Previous Order.
( ) 3. Original departure clearance (zarpe).
( ) 4. Photocopy of the logbook reporting the fishing zone.
( ) 5. Sworn declaration of the fishing trip.
( ) 6. Fuel purchase invoice (original and copy).
( ) 7. Product sale invoice (two copies and original).
( ) 8. Certification of Product Catch (Constancia de Captura del Producto).
( ) 9. Photocopy of the Balance Control Slip (sealed and signed).
( ) 10. Registration and up-to-date in the CCSS Contributory Scheme.
( ) 11. Contract validity and provision of the respective documents.
( ) 12. Validity of the fishing permit.
( ) 13. Others _________________________________________________________________________ OBSERVATIONS ______________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ __________________________________________________________ You are informed that you have a period of 10 business days in accordance with Law No. 8220 to resubmit the corresponding application properly.
Officer's Signature _____________________________________________ Date ___________________________________ Officer's Seal and Signature
(Thus added by agreement AJDIP/119 of March 14, 2008)