Application for Medical Transfer of IFQ

Revised: 04/1/2021

OMB Control Number 0648-0272 Expiration Date:06/30/2021

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

Application
for
Medical Transfer of IFQ

THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH EACH APPLICATION. USE THIS
CHECKLIST TO ENSURE THAT YOU HAVE INCLUDED ALL REQUIRED DOCUMENTATION:
Completed & Signed Application
Copy of the IFQ Permit(s) to be transferred
Block F must be completed and signed by a Licensed Health Care Provider. Regulations do not authorize acceptance of a
medical declaration from any other medical providers.
A medical transfer remains in effect only for the calendar year of the transfer. A separate complete application must be
submitted annually for each medical transfer.
NMFS will not approve a medical transfer of Individual Fishing Quota (IFQ) if the applicant has received a medical transfer in
any 3 of the previous 7 years for any medical condition.
Incomplete applications will not be processed.
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)
2. NMFS Person ID:
3. Date of Birth:
1. Name (Last, First, Middle Initial):
4. Business Mailing Address:

Permanent

5. Business Telephone Number:

Temporary

6. Business Fax Number:

7. E-mail Address:

BLOCK B – TRANSFEREE (NO MEDICAL CONDITION)
2. NMFS Person ID:
3. Date of Birth:
1. Name(Last, First, Middle Initial):
4. Business Mailing Address: Indicate whether

5. Business Telephone Number:

Permanent

Temporary

6. Business Fax Number:

Application for Medical Transfer of IFQ
Page 1 of 7

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

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

Sablefish
1. Halibut
Sablefish
1. Halibut
Sablefish
1. Halibut
Sablefish

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)

OR

___________________
(other method of compensation)

2. What is the total amount being paid for the IFQ in this transaction, including all fees? ______________________

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

Other (explain)

_____________________________________________________________________________________________________

Application for Medical Transfer of IFQ
Page 2 of 7

BLOCK F – MEDICAL DECLARATION
(Must be completed by a Health Care Provider)
1. Name and Title of Treating Health Care Provider:

2. Business Telephone Number:

3. Permanent Business Mailing Address:

4. Type of Health Care Provider:

5. Brief description of the primary medical condition affecting the applicant or applicant’s family member that prevents participation
in the fishery for this calendar year.

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 Health Care Provider:

Application for Medical Transfer of IFQ
Page 3 of 7

7. Date:

NOTE:

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 (MEDICAL CONDITION)

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:

BLOCK H – CERTIFICATION OF TRANSFEREE (NO MEDICAL CONDITION)
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.
Application for Medical Transfer of IFQ
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DISCLOSURE: Providing this information is voluntary; however, the failure to provide complete and accurate information will prevent
NMFS from transferring the QS/IFQ.

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 issuee 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 3 of the previous
7 years for any 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.
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.
Application for Medical Transfer of IFQ
Page 5 of 7

BLOCK A – TRANSFEROR (MEDICAL CONDITION)
1.

Name: Full name as it appears on the TEC.

2.

NMFS Person ID: As it appears on the 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 the TEC.

2.

NMFS Person ID: As found on the 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, or other method of compensation, 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
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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 health care provider defined at 50 CFR part
679.2. The term “health care provider” for purposes of the medical transfer application refers only to an individual licensed
to provide health care services by the state where he or she practices and performs within the scope of their specialty to
diagnose and treat medical conditions as defined by applicable Federal, state, or local laws and regulations. A health care
provider located outside of the United States and its territories who is licensed to practice medicine by the applicable medical
authorities is included in this definition. Certifications from other medical professionals outside of this definition will not be
accepted.
1–3. The Health Care Provider who conducted the medical examination must print or type their name, business telephone
number, and permanent business mailing address.
4.

The Health Care Provider who conducted the medical examination must list the medical category they fall within.

5.

The Health Care Provider conducting the medical examination must provide a brief 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.

6.

The Health Care Provider 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
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