Form 3-202-15 Eagle Take Annual Report

l

u.s. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
u.s.

FISU &.'VILm.lFR
s:£mt:lC£

~

EAGLE TAKE (§22.26) - ANNUAL REPORT
PERMITTEE:
ADDRESS:

PERMIT NUMBER:
REPORT FOR CALENDAR YEAR:
REPORT DUE DATE:

City

Stale

ZipCode

PHONE:

~OP'fl~~

-

Email:

o Check here if reporting a change of name, address, or contact information
INSTRUCTIONS: Type or print the information requested below for each Important Use Area (IUA) identified on your permit during the year covered by this report and return the
completed report to the above address by the due date. Filing an accurate annual report is a condition of your permit. Failure to file a timely report can result in permit suspension.
Please note that the absence of eagles from an IUA you are monitoring will in no way affect the continued validity of your permit. Accurate reporting will play an essential role in
future eagle management. Use a separate supplemental sheet for each IUA. Usc of this form is not mandatory, but you must submit the same information. MAKE SURE YOU
SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT. (50 CFR parts 13, 21, & 22)

IMPORTANT USE AREA :
Identify nest, communal roost, or foraging area. If more than one of one type of IUA is identified on your permit, designate which nest (or roost or foraging area) data applies to.

DATE
EAGLES OBSERVED

TIME

--­

OF DAY

NUMBER OF EAGLES
OBSERVED
(If in large numbers, please estimate)

OBSERVED
BEHAVIOR

P - perched
F - feeding
N - sitting on or
attending nest
IF- in flight

DESCRIPTION OF HUMAN ACTIVITY
AT TIME EAGLES WERE OBSERVED
(e.g., surveying; excavation; pile driving; interior work, etc.)

If activity is completed, enter "Completed"

CERTIFICATION: I certify that the information in this report is true and correct to the best of my knowledge. I understand that any false statement herein may subject me to the
criminal penalties of 18 U.S.C. 100 I.
Signature:
OMB No.

IOl8-xxxx

Expires x/xx/xxxx

Date:
Form 3-202-15

SUPPLEMENTAL SHEET

EAGLE TAKE ANNUAL REPORT

REPORT YEAR

PERMITTEE:

PERMIT NUMBER:

SUPPLEMENTAL PAGE #: - ­

IMPORTANT USE AREA :
Identify nest, communal roost, or foraging area. Use a separate supplemental sheet for each IUA

DATE
EAGLES OBSERVED

TIME
-­

OF DAY

NUMBER OF EAGLES
OBSERVED
(If in large numbers, pleaseestimate)

OBSERVED
BEHAVIOR

P - perched
F - feeding
N - sitting on or
attendingnest
IF- in night

DESCRIPTION OF HUMAN ACTIVITY
AT TIME EAGLES WERE OBSERVED
(e.g., surveying: excavation; pile driving; interior work, etc.)
If activity is completed, enter "Completed"

FWS FORM 3-202-15

Paperwork Reduction Act and the Privacy Act – Notices
In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of 1974 (5 U.S.C. 552a), please be advised that:
1.

The gathering of information on fish and wildlife is authorized by:
(a)
Bald and Golden Eagle Protection Act (16 U.S.C. 668), Title 50, Part 22, of the Code of Federal Regulations (CFR);
(b)
Endangered Species Act of 1973 (16 U.S.C. 1531-1544), Title 50, CFR Part 17;
(c)
Migratory Bird Treaty Act (16 U.S.C. 703-712), Title 50, CFR Part 21;
(d)

Marine Mammal Protection Act of 1972 (16 U.S.C. 1361 et seq. ), Title 50 CFR Part 18

(e)
(f)
(g)
(h)
(i)
(j)

Wild Bird Conservation Act (16 U.S.C. 4901-4916), Title 50, CFR Part 15;
Lacey Act (18 U.S.C. 42); Injurious Wildlife, Title 50 CFR Part 16;
Convention on International Trade in Endangered Species of Wild Flora and Fauna (CITES) (TIAS 8249); Title 50, CFR Part 23.
General Provisions, Title 50 CFR Part 10;
General Permit Procedures, Title 50 CFR Part 13; and
Wildlife (Import/export/transport), Title 50 CFR Part 14.

2.

Information requested in this form is voluntary. However, submission of requested information is a condition of your permit. Response is not required
unless a currently valid Office of Management and Budget (OMB) control number is displayed on the form.

3.

Disclosures outside the Department of the Interior may be made without the consent of an individual if the disclosure is compatible with the purposes for
which the record was collected. (Ref. 68 FR 52611, September 4, 2003)
(a) To subject matter experts, State, Federal, local, and foreign agencies for the purpose of obtaining advice relevant to making a decision on an application
for a permit or when necessary to accomplish a FWS function related to this system of records.
(b) To the public as a result of publishing Federal Register notices announcing the receipt of permit applications for public comment or notice of the
decision on a permit application.
(c) To Federal, State, local, or foreign wildlife and plant agencies for the exchange of information on permits granted or denied to assure compliance with
all applicable permitting requirements.
(d) Captive-bred Wildlife registrants under the Endangered Species Act for the exchange of authorized species, and to share information on the captive
breeding of these species.
(e) To Federal, State, and local authorities who need to know who is permitted to receive and rehabilitate sick, orphaned, and injured birds under the
Migratory Bird Treaty Act and the Bald and Golden Eagle Protection Act; federally permitted rehabilitators; individuals seeking a permitted
rehabilitator with whom to place a bird in need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned, and injured birds.
(f) To the Department of Justice, or a court, adjudicative, or other administrative body or to a party in litigation before a court or adjudicative or
administrative body, under certain circumstances.
(g) To the appropriate Federal, State, tribal, local, or foreign governmental agency responsible for investigating, prosecuting, enforcing, or implementing
statutes, rules, or licenses, when we become aware of a violation or potential violation of such statutes, rules, or licenses, or when we need to monitor
activities associated with a permit or regulated use.
(h) To a congressional office in response to an inquiry to the office by the individual to whom the record pertains.
(i) To the General Accounting Office or Congress when the information is required for the evaluation of the permit programs.
(j) To provide addresses obtained from the Internal Revenue Service to debt collection agencies for purposes of locating a debtor to collect or compromise
a Federal claim against the debtor, or to consumer reporting agencies to prepare a commercial credit report for use by the FWS.

4. For individuals, personal information such as home address and telephone number, financial data, and personal identifiers (social security number, birth date,
etc.) will be removed prior to any release of the application.
5. The public reporting burden on the applicant for information collection varies depending on the activity. The average burden for an eagle incidental take
annual report and monitoring is 10 hours. This burden estimate includes time for reviewing instructions, gathering and maintaining data and completing and
reviewing the form. You may direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer,
U.S. Fish and Wildlife Service, Mail Stop 222, Arlington Square, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.
Freedom of Information Act – Notice
For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any information
that should be considered privileged and confidential business information to allow the Service to meet its responsibilities under FOIA. Confidential business
information must be clearly marked "Business Confidential" at the top of the letter or page and each succeeding page and must be accompanied by a nonconfidential summary of the confidential information. The non-confidential summary and remaining documents may be made available to the public under FOIA
[43 CFR 2.13(c)(4), 43 CFR 2.15(d)(1)(i)].