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pdfRevised: 02/20/2018
OMB Control Number 0648-0272 Expiration Date: 03/31/2018
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
907-586-7202 in Juneau
907 586-7354 fax
Application
for
Medical Transfer of IFQ
A medical transfer remains in effect only for the calendar year of the transfer.
NOTES:
♦
NMFS will not approve a medical transfer of Individual Fishing Quota (IFQ) if the applicant has received a
medical transfer in any 2 of the previous 5 years for the same medical condition.
♦
Block F must be completed and signed by a Licensed Medical Doctor, Advanced Nurse Practitioner, or Primary
Community Health Aide. Regulations do not authorize acceptance of a medical declaration from any other medical
providers.
♦
Attach a copy of the Transferors IFQ permit(s).
♦
A separate complete application must be submitted for each medical transfer. Incomplete applications will not be
processed.
♦
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.
Is the Transferor (medical condition) an initial recipient of Pacific halibut or sablefish quota share who qualifies for a hired master
exception under 50 CFR 679.42(i)(1)?
YES [
]
NO [
]
If YES, STOP. The Transferor is not eligible for a medical transfer.
Does the Transferee (no medical condition) hold a Transfer Eligibility Certificate (TEC)?
YES [ ]
NO [ ]
If NO, STOP. The Transferee is not eligible to receive IFQ by transfer.
BLOCK A – TRANSFEROR INFORMATION (MEDICAL CONDITION)
1. Name:
2. NMFS Person ID:
4. Business Mailing Address: Indicate whether [_] Permanent
5. Business Telephone No.:
3. Date of Birth:
[_] Temporary
6. Business Fax No.:
Application for Medical Transfer of IFQ
Page 1 of 8
7. e-mail Address:
BLOCK B – TRANSFEREE (NO MEDICAL CONDITION)
1. Name:
2. NMFS Person ID:
4. Business Mailing Address: Indicate whether [_] Permanent
[_] Temporary
5. Business Telephone No.:
6. Business Fax No.:
3. Date of Birth:
7. E-mail Address:
BLOCK C – IDENTIFICATION OF IFQ TO BE TRANSFERRED
Use a separate line for each Species, IFQ Area and/or IFQ Permit
1. Halibut
[
]
Sablefish [
]
1. Halibut
[
]
Sablefish [
]
1. Halibut
[
]
Sablefish [
]
1. Halibut
[
]
Sablefish [
]
2. Fishing Year
3. Transferor IFQ Permit Number
4. IFQ Area
5. IFQ Pounds Transferring
2. Fishing Year
3. Transferor IFQ Permit Number
4. IFQ Area
5. IFQ Pounds Transferring
2. Fishing Year
3. Transferor IFQ Permit Number
4. IFQ Area
5. IFQ Pounds Transferring
2. Fishing Year
3. Transferor IFQ Permit Number
4. IFQ Area
5. IFQ Pounds Transferring
REQUIRED SUPPLEMENTAL INFORMATION
Your Application Will Not Be Processed Unless You Provide The Following Information
BLOCK D – 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 8
BLOCK E – 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 Transferee's relationship to the IFQ Holder (check all that apply)?
[
] No Relationship
[
] Relative
[ ] Business Partner
[
] Friend
[
] Family Member
[
Application for Medical Transfer of IFQ
Page 3 of 8
] Other (explain)
BLOCK F – MEDICAL DECLARATION
(may be completed only by a licensed medical doctor, advanced nurse practitioner, or primary community health aide)
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 primary medical condition affecting the applicant or applicant’s family member that prevents participation in the
fishery for this calendar year. Please do not list multiple conditions. (Attach documentation of the medical condition and a
description of the care required).
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:
NOTE:
7. Date:
This application for transfer must be completed and signed by both parties.
Failure to have signatures will result in delays in the processing of this application.
BLOCK G –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 or Authorized Representative:
2. Date:
3. Printed Name of Transferor or Authorized Representative. If Representative, attach authorization:
Application for Medical Transfer of IFQ
Page 4 of 8
BLOCK H – 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 of Transferee or Authorized Representative:
2. Date:
3. Printed Name of Transferee or Authorized Representative. If Representative, attach authorization:
____________________________________________________________________________________________
REPORTING BURDEN STATEMENT
Public reporting burden for this collection of information is estimated to average 1.5 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 the 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 Fishery Conservation and Management Act (16 U.S.C. 1801, et seq.); 3) Some information collected
on this application form is made available to the public on the NMFS, Alaska Region, webpage (www.alaskafisheries.noaa.gov).
Other information is confidential under section 402(b) of the Magnuson-Stevens Act and NOAA Administrative Order 216-100,
which sets forth procedures to protect confidentiality of fishery statistics.
PRIVACY ACT STATEMENT
AUTHORITY: The collection of this information is authorized by the Magnuson-Stevens Fishery Conservation and Management Act,
16 U.S.C. 1801 et seq.
PURPOSE: NMFS uses the information provided on this application to transfer IFQ derived from quota share (QS) held by the
applicant to an eligible QS holder. The information required by this application is necessary to determine that the applicant has a
medical condition that precludes participation in the individual fishing quota (IFQ) fishery for which he or she holds QS.
ROUTINE USES: Disclosure of this information is subject to the published routine uses identified in the Privacy Act System of
Records Notice COMMERCE/NOAA-19, Permits and Registrations for the United States Federally Regulated Fisheries. NMFS may
post some information from this form on its public website (www.alaskafisheries.noaa.gov). In addition, NMFS may share
information submitted on this form with other State and Federal agencies or fishery management commissions, including staff of the
North Pacific Fishery Management Council and Pacific States Marine Fisheries Commission.
DISCLOSURE: Providing this information is voluntary; however, the failure to provide complete and accurate information will
prevent NMFS from transferring the QS/IFQ.
_______________________________________________________________________________________
Application for Medical Transfer of IFQ
Page 5 of 8
INSTRUCTIONS:
Application for Medical Transfer of IFQ
Medical Transfers Remain In Effect only for the Calendar Year of the Transfer
The requirement of 50 CFR part 679.42(c) for an individual fishing quota (IFQ) permit holder to be aboard the vessel during fishing
operations and to sign the IFQ landing report may be waived as described at 50 CFR part 679.42(d). A medical transfer may be
approved if the applicant demonstrates that he or she is unable to participate in the IFQ fishery for which he or she holds IFQ:
♦
Because of a medical condition that precludes participation; or
♦
Because of a medical condition involving an immediate family member that requires the quota share (QS) holder’s full
time attendance.
Eligibility:
To be eligible to receive a medical transfer, an individual halibut or sablefish QS holder:
♦
Must possess one or more catcher vessel IFQ permits.
♦
Must not be an initial issue of Pacific halibut or sablefish quota share that qualifies to hire a master under
50 CFR 679.42(i)(1)
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.
A separate complete application must be submitted for each medical transfer of IFQ.
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 (RAM) at
(800) 304-4846 (#2) or (907) 586-7202 (#2).
When complete, submit the application:
♦
By mail to
NMFS Alaska Region
Restricted Access Management (RAM)
P.O. Box 21668
Juneau, AK 99802-1668
♦
By delivery to
709 West 9th Street, Room 713 Juneau, AK 99801
Note: It is important that all blocks are completed and all necessary documents are attached. Failure to answer any of the questions or
provide attachments could result in delays in the processing of your application.
COMPLETING THE APPLICATION
Indicate if the Transferor (medical condition) is an initial recipient of Pacific Halibut or sablefish quota share who qualifies for a hired
master exception under 50 CFR 679.42(i)(1).
If YES, STOP. The Transferor is not eligible for a medical transfer.
Application for Medical Transfer of IFQ
Page 6 of 8
Indicate whether the Transferee (no medical condition) holds a Transfer Eligibility Certificate (TEC).
If NO, STOP. The Transferee is not eligible to receive IFQ by transfer. Only a person that received QS as an Initial Issuee
or that holds a TEC is eligible to receive QS/IFQ by transfer.
If NO, the transferee must contact RAM for instructions on eligibility procedures and a TEC application.
BLOCK A – TRANSFEROR (MEDICAL CONDITION)
1.
Name: Full name as it appears on QS Holder Summary Report and/or TEC.
2.
NMFS Person ID: As found on QS Holder Summary Report or TEC.
3.
Date of Birth: Birth date of the person.
4.
Business Mailing Address: Include street or P.O. Box number, city, state, and zip code.
Indicate whether permanent or temporary
If temporary, this is the address the transfer documentation will be sent if other than to the permanent address
5–7.
Business Telephone and Fax Numbers: (Include the area codes), and E-mail Address
BLOCK B -- TRANSFEREE (NO MEDICAL CONDITION)
1.
Name: Full name as it appears on QS Holder Summary Report and/or Transfer Eligibility Certificate (TEC).
2.
NMFS Person ID: As found on QS Holder Summary Report or TEC.
3.
Date of Birth: Birth date of the person.
4.
Business Mailing Address: Include street or P.O. Box number, city, state, and zip code.
Indicate whether permanent or temporary
If temporary, this is the address the transfer documentation will be sent if other than to the permanent address
5–7.
Business Telephone and Fax Numbers: (Include the area codes), and E-mail Address
BLOCK C – IDENTIFICATION OF IFQ TO BE TRANSFERRED
Note: A separate line must be completed for each Species, IFQ Area and/or IFQ Permit from which you are
transferring IFQ.
1.
Indicate whether halibut or Sablefish IFQ.
2.
Fishing Year (must be current year).
3.
IFQ Permit Number of Transferor. Must be current year IFQ Permit.
4.
IFQ Regulatory Area.
5.
Actual number of IFQ Pounds to be transferred from the permit listed in #3.
BLOCK D – TRANSFEROR SUPPLEMENTAL INFORMATION
1.
The price per pound of IFQ must be entered for IFQs that are being transferred under a medical transfer. (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 being paid 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.
Application for Medical Transfer of IFQ
Page 7 of 8
BLOCK E – 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 F -- MEDICAL DECLARATION
Federal regulation require that this medical declaration be completed by a licensed medical doctor, advanced nurse
practitioner, or primary community health aide. The term “medical professional” for purposes of the medical transfer
application refers only to licensed medical doctor, advanced nurse practitioner, or primary community health aide.
Certifications from other medical professionals will not be accepted.
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 within.
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.
BLOCK G - CERTIFICATION OF TRANSFEROR
The transferor must sign and print his or her name and date the application. If completed by a representative, attach
authorization. If signing on behalf of an individual, a valid power of attorney for that individual must be provided.
BLOCK H - CERTIFICATION OF TRANSFEREE
The transferee must sign and print his or her name and date the application. If completed by a representative, attach
authorization. If signing on behalf of an individual, a valid power of attorney for that individual must be provided.
Application for Medical Transfer of IFQ
Page 8 of 8
| File Type | application/pdf |
| Author | soliva |
| File Modified | 2018-03-09 |
| File Created | 2018-03-09 |