AJDIP/570-2007, published in the Official Gazette La Gaceta, of February 19, 2008, the following Annexes:
Date: ___________________________ of _________________________________ of ____________________________ Sirs.
Fuel Control and Administration Section Instituto Costarricense de Pesca y Acuicultura In accordance with the legal provisions on the matter, I request the reimbursement of the following fuel:
Owner ________________________________________________________________ ID No. _________________________________ Vessel _______________________________________________________________ Registration _________________________________ Diesel _____________________________________________ Liters Gasoline ______________________________________________ Liters Days of absence _______________________________ between the _______________________ and until the ____________________ Catch: Fish _________________________ Kg. - Shrimp ________________________ Kg. - Other __________________________ Kg.
Name of the applicant _______________________________________________________ ID No. _________________________________ Registered Signature ____________________________________________________________________________________________________ _______________________________________________________________ FOR EXCLUSIVE USE OF THE FUEL CONTROL AND ADMINISTRATION DEPARTMENT Fishing period from ________________________________________ to ______________________________________ Diesel ( ) Gasoline ( ) Days of absence ___________________________________________ Multiplication factor _______________________________________ Authorized liters __________________________________________ Purchase Order No. _________________________________________ OBSERVATIONS:______________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ __________________________________________________________ Received by ____________________________
No. ______________
I. GENERAL INFORMATION
Date: _______________________________________ Place of Sale: ___________________________________________________________ Vessel: _________________________________ Registration: ______________________________________________________________ Owner: __________________________________ ID: ________________________________________________________________ Name of the Captain: ___________________________ ID: ________________________________________________________________ Buyer or Receiving Station: _________________________________________________________________________________________ Fishing Gears: _________________________ Fishing Days: ________________________ Fishing Ground: ___________________________
II. CATCH DETAIL
| COMMERCIAL GROUP | KILOS | PRICE | VALUE IN ¢ |
|---|---|---|---|
| GRAND TOTAL |
III. OPERATING EXPENSES
| ITEM | TOTAL IN ¢ |
|---|---|
| FUEL | |
| LUBRICANTS | |
| ICE | |
| PROVISIONS | |
| BAIT | |
| OTHERS | |
| GRAND TOTAL |
SIGNATURE OF THE FISHERMAN: __________________________________________________________________
(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 _______, 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: _____________________________________________________________________
AT A COMPETITIVE PRICE Vessel: ______________________________________________ Registration: ___________________________________________ Owner's Name: _____________________________________ ID No.: ___________________________________________ Name of person withdrawing: ___________________________________ID No.: ___________________________________________ Name of the Distributor: _________________________________________________________________________________________ Distributor Seal | Purchase Order No. | Order issue date | Liters authorized INCOPESCA | Liters Withdrawn Station | Fuel Withdrawal Date | Pump Balance | Tank Balance | Signature of the Beneficiary or Authorized Person | | --- | --- | --- | --- | --- | --- | --- | --- | _______________________________________ SIGNATURE OF THE BENEFICIARY
UNLOADS IN A PLACE DIFFERENT FROM ITS OPERATING BASE Date: ______ / ______ / 20 _____. Office: _____________________________ Vessel Name: ____________________________________________________ Registration No.: _______________________________ Operating Base: _________________________________________________________________________________________________ Owner: ____________________________________________________________ ID No.: __________________________________ | Last Purchase Order No. | Order issue date | Liters authorized INCOPESCA | Registered Balance(s) | Last accounted fishing period (Departure and Arrival) | Contract expiration date | | --- | --- | --- | --- | --- | --- | (Attach Signature Registration Card) | Certificate of Seaworthiness expiration date | Fishing License expiration date | Annual payment due date | | --- | --- | --- | (Attach fishing license and proof of income) Observations:______________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ _______ Official's Name: ___________________________________________________________ Official's Signature: ______________________________________ Date: ___ / ___ / 20 ___ SEAL
FOR THE PROCESSING OF COMPETITIVELY PRICED FUEL.
INDIVIDUAL PROCEDURE VES. _________________________________ REGISTRATION _____________________________ EXPED. ___________________________ MARK WITH AN X ( ) 1. Complete fuel application.
( ) 2. Previous Order.
( ) 3. Original departure clearance (Zarpe).
( ) 4. Photocopy of the logbook where the fishing zone is reported.
( ) 5. Affidavit of the fishing trip.
( ) 6. Fuel purchase invoice (original and copy).
( ) 7. Product sales invoice (two copies and original).
( ) 8. Product Catch Certificate.
( ) 9. Photocopy of the Balance Control Slip (stamped and signed).
( ) 10. Registration and up-to-date in the CCSS Contributory Regime.
( ) 11. Validity of the Contract 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 submit the corresponding procedure again in proper form.
Received by user ________________________________________ Date _______________________________________ Official's Seal and Signature
FOR THE PROCESSING OF COMPETITIVELY PRICED FUEL.
FISHERMEN'S ORGANIZATIONS
| Vessels | Registration | Vessels | Registration |
|---|
MARK WITH AN X ( ) 1. Complete fuel application.
( ) 2. Previous Order.
( ) 3. Original departure clearance (Zarpe).
( ) 4. Photocopy of the logbook where the fishing zone is reported.
( ) 5. Affidavit of the fishing trip.
( ) 6. Fuel purchase invoice (original and copy).
( ) 7. Product sales invoice (two copies and original).
( ) 8. Product Catch Certificate.
( ) 9. Photocopy of the Balance Control Slip (stamped and signed).
( ) 10. Registration and up-to-date in the CCSS Contributory Regime.
( ) 11. Validity of the Contract 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 submit the corresponding procedure again in proper form.
Official's Signature _____________________________________________ Date ___________________________________ Official's Seal and Signature