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pdfCreated: 06/21/2007
OMB Control No.: 0648-xxxx
Expiration Date: xx/xx/xxxx
APPLICATION FOR
MEDICAL TRANSFER OF IFQ
U.S. Dept. of Commerce/NOAA
National Marine Fisheries Service
Restricted Access Management
P.O. Box 21668
Juneau, AK 99802-1668
(800) 304-4846 toll free / 586-7202 in Juneau
(907) 586-7354 fax
NOTE: A separate application must be submitted for each IFQ Medical Transfer (MT). Medical
Transfers will remain in effect only for the calendar year of the transfer.
BLOCK A
Does the Transferee (No Medical Condition) hold a Transfer Eligibility Certificate (TEC)?
Yes [
]
No [
]
Does the Transferor (Medical Condition) qualify for a hired master exception under 50 CFR 679.42(i)(1)?
Yes [
]
No [
]
BLOCK B – ATTACHMENTS
USE THIS LIST TO ENSURE YOUR APPLICATION IS COMPLETE.
INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
NOTE: FAXED APPLICATIONS ARE NOT ACCEPTABLE. PLEASE SUBMIT ORIGINALS.
[ ]
Completed, signed, and notarized application
[ ]
Copy of permit or QS Certificate
[ ]
Declaration from certified medical professional
BLOCK C – TRANSFEROR INFORMATION (MEDICAL CONDITION)
1. Name:
2. NMFS Person ID:
3. Date of Birth:
4. Permanent Business Mailing Address:
5. Temporary Business Mailing Address (see
instructions):
6. Business Telephone No.:
7. Business Fax No.:
Application for Medical Transfer of IFQ
Page 1 of 9
8. e-mail Address (if any):
.
BLOCK D – TRANSFEREE (NO MEDICAL CONDITION)
1. Name:
2. NMFS Person ID:
3. Date of Birth:
4. Permanent Business Mailing Address:
5. Temporary Business Mailing Address (see instructions):
6. Business Telephone No.:
7. Business Fax No.:
8. E-mail Address (if any)
BLOCK E – IDENTIFICATION OF IFQ TO BE TRANSFERRED
1. Halibut
Sablefish
[ ]
[ ]
or
2. IFQ Regulatory Area:
3. Number of Units:
4. Numbered To and From (Serial Numbers are shown
on the QS Certificate):
5. Actual Number of IFQ Pounds:
6. Transferor (Seller) IFQ Permit Number:
7. Fishing Year: 20______
REQUIRED SUPPLEMENTAL INFORMATION
YOUR APPLICATION WILL NOT BE PROCESSED UNLESS YOU PROVIDE THE FOLLOWING INFORMATION
BLOCK F – TRANSFEROR SUPPLEMENTAL INFORMATION
1. Give the price per pound (including leases) $ ____________________________/pound of IFQ (Price divided by
IFQ pounds)
Including fees
2. What is the total amount being paid for the IFQ in this transaction, including all fees? ______________________
Application for Medical Transfer of IFQ
Page 2 of 9
BLOCK G – TRANSFEREE SUPPLEMENTAL INFORMATION
1. What is the primary source of financing for this transfer (check one)?
Personal resources (cash)
[
]
AK Com. Fish & Ag. Bank [
] Received as a gift
[
]
Private bank/credit union
[
]
Transferor/seller
] NMFS loan program
[
]
Alaska Dept. Of Commerce [
]
Processor/fishing company [
] Other (explain)
[
]
[
2. How was the IFQ located (check all that apply)?
Relative
[
]
Advertisement/public notice [
]
Broker
[
]
Personal friend
[
]
Casual acquaintance
]
Other (explain)
[
]
[
]
[
3. What is the Buyer's relationship to the IFQ Holder (check all that apply)?
No relationship
[
] Relative
[ ]
Business partner
[
] Other (explain)
BLOCK H – MEDICAL DECLARATION
(to be completed by licensed medical doctor, advanced nurse practitioner, or primary community health aid)
1. Name of Treating Medical Professional:
2. Business Telephone Number:
3. Permanent Business Mailing Address:
4. Type of Medical Professional:
Licensed Medical Doctor
[
]
Advanced Nurse Practitioner
[
]
Primary Community Health Aide
[
]
5. Description of the medical condition affecting the applicant or applicant’s family member (attach documentation of
the medical condition and a description of the care required):
Application for Medical Transfer of IFQ
Page 3 of 9
I acknowledge the requirements for receiving a Medical Transfer and certify that, to the best of my knowledge
and belief, the information presented here is true, correct, and complete. The medical condition described above
would prevent the applicant from participating in the IFQ fishery or, in the case of a family member, require
continuous care that would preclude the applicant’s participation in the IFQ fishery.
6. Signature of Treating Medical Professional:
7. Date:
NOTE: This application for transfer must be completed, signed, and notarized by both parties. Failure to
have signatures properly notarized will result in delays in the processing of this application.
BLOCK I –CERTIFICATION OF TRANSFEROR (SELLER)
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, the
information presented here is true, correct, and complete.
1. Signature of Transferor (Seller) or Authorized Agent:
2. Date:
3. Printed Name Transferor (Seller) or Authorized Agent Note: If agent, attach authorization:
4. Notary Public Signature:
ATTEST
5. Affix Notary Stamp or Seal Here:
6. Commission Expires:
Application for Medical Transfer of IFQ
Page 4 of 9
BLOCK J – CERTIFICATION OF TRANSFEREE (BUYER)
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, the
information presented here is true, correct, and complete.
1. Signature Transferee (Buyer) or Authorized Agent:
2. Date:
3. Printed Name Transferee (Buyer) or Authorized Agent Note: If agent, attach authorization:
4. Notary Public Signature:
ATTEST
5. Affix Notary Stamp or Seal Here:
5. Commission Expires:
________________________________________________________________________________________________________________________
REPORTING BURDEN STATEMENT
Public reporting for this collection of information is estimated to average 2 hours per response, including the time for reviewing the
instructions, searching the 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 aspect of this collection of information,
including suggestions for reducing the burden, to Assistant Regional Administrator, Sustainable Fisheries Division, NOAA National
Marine Fisheries Service, P.O. Box 21668, Juneau, AK 99802-1668.
ADDITIONAL INFORMATION
Before completing this form please note the following: 1) Notwithstanding any other provision of law, no person is required to
respond to, nor shall any person be subject 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;
2) This information is mandatory and is required to manage commercial fishing efforts under 50 CFR part 679 and under section
402(a) of the Magnuson-Stevens Act (16 U.S.C. 1801, et seq.); 3) Responses to this information request are confidential under section
104(b) of the Magnuson-Stevens Act). They are also confidential under NOAA Administrative Order 216-100, which sets forth
procedures to protect confidentiality of fishery statistics.
Application for Medical Transfer of IFQ
Page 5 of 9
Created: 06/21/2007
INSTRUCTIONS:
Application for
Medical Transfer of IFQ
In the event of a medical condition affecting a QS holder or an immediate family member of a QS holder that prevents the
QS holder from being able to participate in the halibut or sablefish IFQ fisheries, a medical transfer may be approved for
the IFQ derived from the QS held by the person affected by the medical condition.
A medical transfer will be approved if the QS holder demonstrates that:
He or she is unable to participate in the IFQ fishery for which he or she holds QS because of a medical condition
that precludes participation by the QS holder; or
He or she is unable to participate in the IFQ fishery for which he or she holds QS because of a medical condition
involving an immediate family member that requires the QS holder’s full time attendance.
Eligibility.
To be eligible to receive a medical transfer, a QS holder must:
Possess one or more catcher vessel IFQ permits; and
Not qualify for a hired master exception under paragraph § 679.42(i)(1).
Restrictions.
A medical transfer shall be valid only during the calendar year for which the permit is issued;
A medical transfer will be issued only for the IFQ derived from the QS held by the applicant;
NMFS will not approve a medical transfer if the applicant has received a medical transfer in any
2 of the previous 5 years for the same medical condition.
Note: A Separate Application must be submitted for each Medical Transfer (MT) of IFQ.
The original application must be submitted — an application sent by facsimile will not be processed.
Please allow at least ten working days for your application to be processed. Items will be sent by first class mail, unless
you provide alternate instructions and include a prepaid mailer with appropriate postage or corporate account number for
express delivery.
If you need assistance in completing this application or need additional information, call Restricted Access Management
at (800) 304-4846 (#2) or (907) 586-7202 (#2).
A QS holder may apply for a medical transfer by submitting a medical transfer application to the Alaska Region, NMFS.
A QS holder who has received an approved medical transfer from RAM may transfer the IFQ derived from his or her own
QS to an individual eligible to receive IFQ.
A medical transfer application is available at http://www.fakr.noaa.gov or by calling 1-800-304-4846.
Application for Medical Transfer of IFQ
Page 6 of 9
When completed, mail or deliver the application to
NMFS Alaska Region
Restricted Access Management (RAM)
P.O. Box 21668
Juneau, AK 99802-1668
or
709 West 9th Street, Room 713
Note: It is important that all blocks are completed and all necessary documents are attached. Failure to answer any of
the questions, provide attachments, or to have signatures notarized could result in delays in the processing of your
application.
BLOCK A
Any person that received QS/IFQ as an Initial Issuee or that holds a Transfer Eligibility Certificate (TEC) is eligible to
receive QS/IFQ by transfer. If you answer "No," the transferee (buyer) will need to contact RAM for instructions on
eligibility procedures and a TEC application form.
Persons who qualify for a hired master exception under 50 CFR §679.42(i) are ineligible to receive an EMT. If you check
“Yes,” the submitted EMT application will be denied.
BLOCK B – ATTACHMENTS
Use this list as a guide to make sure you have included all the necessary items in the mailing of your application. This
will ensure timely processing of your transfer application. You must attach the completed Medical Declaration and a
copy of the IFQ permit or QS certificate to be considered for a Medical Transfer.
BLOCKS C & D
TRANSFEROR (SELLER) AND TRANSFEREE (BUYER)
1.
Name: Full name as it appears on QS Certificate and/or Transfer Eligibility Certificate (TEC).
2.
NMFS Person ID: As found on QS Certificate or TEC.
3.
Date of Birth: Birth date of the person.
4.
Permanent Business Mailing Address: Include street or P.O. Box number, city, state, and zip code.
5.
Temporary Business Mailing Address: Address you want the transfer documentation sent if somewhere other than to the permanent address. Include street or P.O. Box number, city, state, and zip
code.
6-8
Business Telephone and Fax Numbers: (Include the area codes), and E-mail Address (if any).
BLOCK E – IDENTIFICATION OF IFQ TO BE TRANSFERRED
1.
Indicate whether halibut or Sablefish IFQ.
Application for Medical Transfer of IFQ
Page 7 of 9
2.
IFQ Regulatory Area:
3.
Number of Units:
4.
Range of serial numbers for IFQ to be transferred, numbered To and From (Serial Numbers are shown on
the QS Certificate):
5.
Actual Number of IFQ Pounds to be transferred
6.
Transferor (Seller) IFQ Permit Number
7.
Indicate Fishing Year
BLOCK F – TRANSFEROR SUPPLEMENTAL INFORMATION
1.
The price per pound of IFQ must be entered for IFQs that are being transferred under an EMT. (To derive
the number of dollars per unit of QS or pound of IFQ, divide the total amount paid, including fees, by the
number of QS units or the number of IFQ pounds being transferred.)
2.
The total amount entered should include any and all monies collected on behalf of the seller for the
shares involved, including any fees that will be paid out to other parties for the expenses of brokering
or assisting in the sale of these shares.
BLOCK G – TRANSFEREE SUPPLEMENTAL INFORMATION
1.
Indicate the primary source of financing for this transfer (check one).
2.
Indicate how the IFQ was located (check all that apply).
3.
Indicate Buyer's relationship to the IFQ Holder (check all that apply).
BLOCK H -- MEDICAL DECLARATION
(Completed by licensed medical doctor, advanced nurse practitioner,
or primary community health aide.)
1-3. The medical professional who conducted the medical examination must print or type their name, business
telephone number, and permanent business mailing address.
4.
The medical professional who conducted the medical examination must check the box indicating the
medical category they fall in.
5.
The medical professional conducting the medical examination must provide a concise description of the
medical condition affecting the applicant or the applicant’s family member including verification that the
applicant is unable to participate in the IFQ fishery for which he or she holds IFQ permits during the IFQ
season because of the medical condition and, for an affected family member, a description of the care
required. The medical professional may attach the original medical report or additional information if
necessary.
6.
The medical professional who conducted the medical examination must sign and date the declaration.
Application for Medical Transfer of IFQ
Page 8 of 9
BLOCK I - CERTIFICATION OF TRANSFEROR
1.
Sign and print your name and date the application. If completed by a representative, attach authorization..
2.
A Notary Public must attest, affix Notary Stamp, and provide date commission expires. The Notary
Public cannot be the person(s) submitting this application.
BLOCK J - CERTIFICATION OF TRANSFEREE
1.
Sign and print your name and date the application. If completed by a representative, attach authorization..
2.
A Notary Public must attest, affix Notary Stamp, and provide date commission expires. The Notary
Public cannot be the person(s) submitting this application.
Application for Medical Transfer of IFQ
Page 9 of 9
| File Type | application/pdf |
| File Title | C:\PRA\OMB83I pre-ps.WP6.wpd |
| Author | rroberts |
| File Modified | 2007-07-02 |
| File Created | 2007-07-02 |