Free Fisherman's Fund - Alaska

Fl­41Vessel Owner (Employer) ­ Crewman Agreement Regarding Medical and Related Transportation or Other Expenses

I,

, vessel owner/operator of the F/V , crewman on this vessel have agreed that any medical

and or

related expenses paid by the said vessel owner or operator are not business expenses of the vessel and were paid as a loan to the said crewman or paid directly to the provider of the services. If a loan, these expenses have been or will be deducted from the crewman's share or be paid. Further, any expenses eligible for reimbursement by the Alaska Commercial

Fishermen's Fund that have been paid by the vessel owner are authorized by the said crewman to be paid directly to the said vessel owner or operator. A Social Security number must be provided for the vessel owner in order to reimburse payment to him/her.

_____________________________________________ _______ Vessel Owner Signature and Address _____________________________________________________ Vessel Owner Social Security/Tax I.D. Number _____________________________________________________ Crewman Signature ________________________________________ Crewman Claim Number

Date ___________

Date ____________

12/5/00 Rev.