QS/IFQ designated beneficiary form

Revised: 06-28-2011

OMB Control No. 0648-0272

QS/IFQ BENEFICIARY
DESIGNATION
FORM

Expiration Date: 10-31-2011

U.S. Dept. of Commerce/NOAA
National Marine Fisheries Service
Restricted Access Management Program RAM)
P.O. Box 21668
Juneau, AK 99802-1668
(800) 304-4846 toll free / 586-7202 in Juneau
(907) 586-7354 fax

Use this form to designate the surviving spouse, or in the absence of a surviving spouse, an immediate family
member to be the beneficiary for these purposes.
NOTE: QS/IFQ can only be held by a U.S. citizen.
BLOCK A - IDENTIFICATION OF QS HOLDER
2. NMFS Person ID:

1. Name:
3. Business Mailing Address:

4. Business Telephone Number:

5. Business Fax Number:

6. Business E-mail Address:

BLOCK B – IDENTIFICATION OF BENEFICIARY
1. Name:

2. NMFS Person ID:

3. Business Mailing Address:

4. Business Telephone Number:

5. Business Fax Number:

6. Business E-mail Address:

BLOCK C - RELATIONSHIP OF BENEFICIARY TO QS HOLDER
Is the beneficiary named on this form the spouse of the QS holder?
YES [ ]

NO [ ]

If NO, explain the immediate relationship of the beneficiary to the QS holder:

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QS/IFQ Beneficiary Designation Form
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BLOCK D -- SIGNATURE
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.
Signature of Beneficiary:

Date:

Printed Name of Beneficiary (Note: If completed by an authorized representative, attach authorization):

Notary Public:

ATTEST

Affix Notary Stamp or Seal Here:

Commission Expires:

________________________________________________________________________________________________________________________
PUBLIC REPORTING BURDEN STATEMENT
Public reporting burden for this collection of information is estimated to average 30 minutes 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 the burden estimate or any other aspect of this collection of information, including suggestions for reducing
the burden estimate or any other aspect of this collection of information, to Assistant Regional Administrator, Sustainable Fisheries Division, NOAA
National Marine Fisheries Service, Alaska Region, 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 402(b) of the Magnuson-Stevens Act (16 U.S.C. 1801, et seq.). They are also confidential
under NOAA Administrative Order 216-100, which sets forth procedures to protect confidentiality of fishery statistics.
________________________________________________________________________________________________________________________

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INSTRUCTIONS
QS/IFQ BENEFICIARY DESIGNATION FORM
Quota Share (QS) holders may provide NMFS with the name of a designated beneficiary to receive survivorship
transfer privileges in the event of the QS holder’s death. If the QS holder does not leave a surviving spouse,
he/she may name an immediate family member to be the beneficiary.
NMFS will allow the transfer of IFQ only (lease) of any QS/IFQ transferred to the beneficiary by right of
survivorship, for a period of 3 years following the death of the original QS holder.
GENERAL INFORMATION
Type or print legibly in ink and retain a copy of completed application for your records.
Please allow at least 10 working days for your application to be processed.
An application may be submitted to NMFS by mail or delivery. Fax submittal is not acceptable due to the Notary
requirements. RAM will not process an application that does not bear original signatures (faxed applications will be
returned). All signatures must be witnessed by a Notary Public (or, in some remote areas, the community Postmaster or
Postmistress).
When completed, submit the original application
by mail to:

NMFS, Alaska Region
Restricted Access Management (RAM)
P.O. Box 21668
Juneau, AK 99802-1668

or deliver to:

Room 713, Federal Building
709 West 9th Street

Items will be sent to you by first class mail, unless you provide alternate instructions and include a prepaid mailer with
appropriate postage or corporate account number for express delivery. Additional information is available from RAM, as
follows:
Website: http://www.alaskafisheries.noaa.gov/ram/default.htm
Telephone (toll free): 800-304-4846 (press “2”)
Telephone (in Juneau): 907-586-7202 (press “2”)
e-Mail: [email protected]

COMPLETING THE APPLICATION
BLOCK A – IDENTIFICATION OF QUOTA SHARE (QS) HOLDER
1. Enter name of quota share holder
2. NMFS Person ID: NMFS will supply this number, if you do not already have one.
3. Enter permanent mailing address, including street or P.O. Box, city, state, and zip code.
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4. Business Telephone Number, Business Fax Number, and Business E-mail address (if available)

BLOCK B – IDENTIFICATION OF BENEFICIARY
1. Enter name of beneficiary.
2. NMFS Person ID: NMFS will supply this number, if you do not already have one.
3. Enter permanent mailing address, including street or P.O. Box, city, state, and zip code.
4. Business Telephone Number, Business Fax Number, and Business E-mail address (if available)

BLOCK C - RELATIONSHIP OF BENEFICIARY TO QS HOLDER
Indicate if the beneficiary named on this form is the spouse of the QS holder.
If NO, explain the immediate relationship of the beneficiary to the QS holder:

BLOCK D -- SIGNATURE
The beneficiary must enter printed name, signature, and date signed. Signature indicates that the information presented is
true, correct, and complete.
The Notary Public must enter name, date commission expires, and apply Notary Public stamp or seal.

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