Form 3-154a Part I - Certification

UNITED STATES
DEPARTMENT OF THE INTERIOR
Fish and Wildlife Service
Division of Federal Assistance

PART I - CERTIFICATION
A. Hunting License Holders
Pursuant to Federal Aid in Wildlife Restoration Act, as amended (50 Stat. 917; 16 U.S.C.
Sec. 669), and to the Rules and Regulations of the Secretary of the Interior made and
published thereunder, I CERTIFY that in the State of __________________, during the
year ending ______________(mm/dd/yyyy), there were ______________ persons holding paid
licenses to hunt.

B. Sport Fishing License Holders
Pursuant to Federal Aid in Sport Fish Restoration Act, as amended (50 Stat. 917; 16 U.S.C.
Sec. 777), and to the Rules and Regulations of the Secretary of the Interior made and
published thereunder, I CERTIFY that in the State of __________________, during the
year ending ______________(mm/dd/yyyy), there were ______________ persons holding paid
licenses to fish for sport or recreation.

______________

____________________________

(Date)

(Signature)

____________________________
(Title)
In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501) and the Privacy Act of 1974 (U.S.C. 552), please be advised that:
The gathering of this information from applicants is authorized under the Federal Aid in Sport Fish Restoration Act (16 U.S.C. 777-777k) and the Federal Aid in Wildlife Restoration
Act (16 U.S.C. 669-669i). Information from this form will be used to apportion funds to States using formulas in the Acts. Your participation in completing this form is required to obtain
benefits. For guidance in completing this form, see Title 50 CFR 80.10. Once submitted, this form becomes public information and is not protected under the Privacy Act. The public
reporting burden for this form is estimated to average 12 hours per response, including time for gathering information, completing, reviewing and obtaining signature. Direct comments
to the Service Information Collection Clearance Officer, U.S. Fish and Wildlife Service, MS 222-ARLSQ; 1849 C Street, NW, Washington, DC 20240.
An agency may not conduct and a person is not required to complete a collection of information unless a current valid OMB control number is displayed.

FWS Form 3-154a
(Revised 11/06)

OMB Control No. 1018-0007
Expiration Date: XX/XX/XXXX

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