EOEEA-DFG

Name(Required)

First Last

DMF Permit ID#(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Your Vessel Information

Vessel Name(Required)

Length(Required)

MS/DOC No(Required)

Vessel Homeport(Required)

Gear Conflict or Catastrophic Loss

Please be as specific as possible when filling out form.

Date of Incident(Required)

Time (AM/PM)(Required)

Location (Lat/Lon and/ or description of geographic location )(Required)

If other vessel(s) lost gear in the conflict, please list them below

F/V Name

MS/Doc #

Name

F/V Name

MS/Doc #

Name

Please list the vessel(s) that caused the conflict (if applicable)

F/V Name

MS/Doc #

Name

F/V Name

MS/Doc #

Name

Description of Event(s)

Please include type of gear lost, total amount of gear lost (# of pots, gillnets, etc.) and time lost due to lost gear(Required)

Type of Gear Lost(Required)

Amount of Gear Lost(Required)

Value of Gear Lost($)(Required)

Did you contact the Massachusetts Environmental Police or Coast Guard during or after the conflict?(Required)

Yes

Witness Information

(1) Name

First Last

(1) DMF Permit ID #

Phone

Address

Street Address Address Line 2 City State ZIP Code

(2) Name

First Last

(2) DMF Permit ID #

Phone

Address

Street Address Address Line 2 City State ZIP Code

Other Comments