Fillable VMS REIMBURSEMENT REQUEST FORM

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VMS REIMBURSEMENT REQUEST FORM

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PACIFIC STATES MARINE FISHERIES COMMISSION
205 SE Spokane Street, Suite 100
Portland, OR 97202
Tel: (503) 595-3100 Fax: (503) 595-3444
www.psmfc.org
VMS REIMBURSEMENT REQUEST FORM
PSMFC Form VMS-2015-1.0 Form Effective Date 5.2015 (Previous Versions Obsolete) Page 1 of 2
Mail or Fax to Pacific States Marine Fisheries Commission
This reimbursement opportunity is available to fishing vessel owners and/or operators that have purchased an approved E-MTU device in
order to comply with fishery management regulations. For units purchased on or after 2.1.2008, the reimbursable expense is the
purchase price of a type-approved E-MTU for which the owner and/or operator holds a valid commercial fishing permit or license, not to
exceed a maximum of $3,100.00.
HOW TO REQUEST REIMBURSEMENT FOR VMS:
1. Purchase, install, and activate a NOAA OLE Type-Approved VMS unit.
2. Contact NOAA OLE VMS Helpdesk at 1.888.219.9228 to obtain four-digit reimbursement confirmation number.
3. Complete and sign this reimbursement request form or visit www.psmfc.org
for web form.
4. Mail or fax the reimbursement request form, a copy of the itemized sales invoice, a copy of the Federal Fisheries Permit and a
copy of the vessel’s Certificate of Documentation or State Registration to Pacific States Marine Fisheries Commission 205 SE
Spokane Street, Suite 100, Portland, OR 97202 – Fax: 503.595.3444.
For additional help with completing this form, consult the VMS Request Form Instructions or contact PSMFC at 503.595.3100.
I. VESSEL INFORMATION
Vessel Name:
Region (select one):
Alaska (AK) Northeast (NE) Northwest (NW) Pacific Islands (PI) Southeast (SE)
Permit Number:
Fishery/Permit Type:
USCG Documentation Number:
State Registration Number:
II. VESSEL OWNER INFORMATION
As it appears on permit, title, license, registration, etc. If under business ownership, provide business name and owner name.
First Name:
MI:
Last Name:
Business Name:
Mailing Address:
Phone Number:
Email Address:
III. NOAA OLE COMPLIANCE AND REIMBURSEMENT CONFIRMATION INFORMATION
NOAA OLE Issued Confirmation Number:
Date Confirmation Issued:
PACIFIC STATES MARINE FISHERIES COMMISSION
205 SE Spokane Street, Suite 100
Portland, OR 97202
Tel: (503) 595-3100 Fax: (503) 595-3444
www.psmfc.org
VMS REIMBURSEMENT REQUEST FORM
PSMFC Form VMS-2015-1.0 Form Effective Date 5.2015 (Previous Versions Obsolete) Page 2 of 2
Mail or Fax to Pacific States Marine Fisheries Commission
IV. VMS TRANSMITTER INFORMATION
VMS Transmitter ID and/or serial number must be on paid itemized sales invoice in order for processing of reimbursement request.
Transmitter ID/Serial Number:
Vessel Email Address:
VMS Brand:
VMS Model:
Installation Date:
Installed By:
Electronics Dealer:
Dealer Contact:
Dealer Phone:
V. REIMBURSEMENT PAYMENT INFORMATION
The applicant is the Vessel Owner or Operator responsible for purchasing the installed VMS transmitter unit, and completing and
signing this form.
Applicant:
Vessel Owner Vessel Operator
First Name:
MI:
Last Name:
Business Name:
Mailing Address:
Phone Number:
Email Address:
VI. APPLICANT SIGNATURE
Under penalties of perjury, I hereby declare that I, the undersigned, completed this application and the information contained herein
is true, correct, and complete to the best of my knowledge. I also declare that the VMS transmitter described above has been
installed on board the vessel listed above and is intended for use only on this vessel.
Applicant First Name: MI: Last Name:
Business Name:
Applicant Signature: Date:
DO NOT WRITE BELOW THIS POINT – PSMFC OFFICE USE ONLY
DATE RECEIVED
DATE APPROVED
CONFIRM DATE
UNIT TYPE
APPROVED AMT
PAY TO
INVOICE DATE
INVOICE NUMBER
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VMS REIMBURSEMENT REQUEST FORM

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Completed 3 November 2021

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