Form 3-202-4 Rehabilitation Annual Report

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
(See attached addresses)
REHABILITATION ANNUAL REPORT - REPORT YEAR ___________
Report Due: ___________
PERMITTEE:

PERMIT NUMBER:_________________

ADDRESS:

PHONE NUMBER: ______________________________________

E-Mail: _____________________________________________________
City
State
Zip Code
_____ Check here if reporting a change of name, address, or contact information

INSTRUCTIONS: Please type or print the information requested below for all migratory birds (see 50 CFR 10.13) held under your permit
during the report year, and return the completed report to the above address by January 31 of the following year. Use of this form is not
mandatory, but the same information must be submitted. A supplemental sheet is available if needed. Do not include species other than migratory
birds in your report. Filing an annual report is a condition of your permit. Failure to file a timely report could result in suspension of your permit.
You must submit a report even if you had no activity during the year. Make sure you sign the certification at the end of the form. (Ref. 50
CFR parts 13 & 21)
DISPOSITION CODES: R=Released; T=Transferred; P=Pending; E=Euthanized; D=Died.
A. BIRDS HELD OVER. Please list individual birds that were held over from the last report year for continued care, and provide the following information. For
DISPOSITION, check appropriate column. Also complete section E for all Transfers.

Common Name

Date
Acquired

Nature of Injury

Disposition (check one)
R
T
E
D

Date of
Disposition

B. NEW ACQUISITIONS. Please provide a summary of all birds acquired during the report year, categorized by species. The quantity in the
Received column should equal the sum of the quantities in the Disposition column. (For example: Robins: 14 - 10, 0, 1, 2, 1). Also complete

sections D and E for Pending and Transferred birds, respectively. All birds, including birds reported in C, D, and E, must be reported here.
Common Name

Total Number
Received

Released

Disposition (enter quantity)
Euthanized
Transferred
Pending

Died

CERTIFICATION: I certify that the above information 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. 1001.
Signature:
Form 3-202-4

Rev 7/2007

Continue to next page

Date:
OMB No. 1018-0022

Expires x/xxxxxx

REHABILITATION PERMIT ANNUAL REPORT - YEAR
PERMIT NO.
(Pg. 2)
C. REPORTED INJURIES. Please complete for any individual birds received that were shot, poisoned (confirmed), electrocuted,
trapped, or otherwise injured or killed as the result of a potentially criminal activity. (Such injuries should have been reported
immediately.) DISPOSITION CODES: R=Released; T=Transferred; P=Pending; E=Euthanized; D=Died.
Common Name

Date
Acquired

Cause/Nature
of Injury

R

Disposition (check one)
T
P
E

D

Source
(County & State)

D. STILL PENDING. Please complete for any individual birds still held as of 12/31 of the report year. Please identify any birds you maintain as foster parents
with a circled “F” next to their common name.

Common Name

Date Acquired

Nature of Injury

Proposed Disposition (check one)
R
T
E

E. TRANSFERS. Please complete for individual birds you transferred during the report year (1/1-12/31). For Permit Number or Address,
provide the permit number if applicable; if not applicable, provide address. For Purpose of Transfer, use the following codes: R = Release; C
= Continued Care; Live-E/S = Live- Education or Scientific Purposes; Dead-E/S = Dead-Education or Scientific Purposes.
Transferred to (Recipient)
Purpose
Common Name
of Transfer
Name
Permit Number or Address
Date

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SUPPLEMENTAL SHEET - REHABILITATION ANNUAL REPORT - Year________ PERMIT NO.
__
Page ___
B. NEW ACQUISITIONS. Please provide a summary of all migratory birds acquired during the report year, categorized by species. The quantity
in the Received column should equal the sum quantities in the Disposition columns. (For example: Robins: 14 - 10, 0, 1, 2, 1). Also complete

sections D and E for Pending and Transferred birds, respectively. All birds, including birds reported in C, D, and E, must be reported here.
Common Name

Form 3-202-4

Rev 7/2007

Total Number
Received

Released

Disposition (enter quantity)
Transferred
Pending
Euthanized

OMB No. 1018-0022

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Died

SUPPLEMENTAL SHEET - REHABILITATION ANNUAL REPORT - Year_________ PERMIT NO.
___
Page ____
A, C, or D. Use as additional space for completing sections A, C, and D. Please indicate in the left column the letter of the section that corresponds
to the information you have provided below. DISPOSITION CODES: R=Released; T=Transferred; P=Pending; E=Euthanized; D=Died.
(A) Date of Disposition or
Date
Cause/Nature
Disposition (check one)
(B) Source: County&State
Common Name
Acquired
of Injury
R
T
P
E
D

E.

TRANSFERS. Please complete for individual birds you transferred during the report year (1/1 - 12/31). For Permit Number or Address,
provide the permit number if applicable; if not applicable, provide address. For Purpose of Transfer, use the following codes:
R = Release; C = Continued Care; Live-E/S = Live- Education or Scientific Purposes; Dead-E/S = Dead - Education or Scientific Purposes.
Purpose of
Transferred to (Recipient)
Transfer
Common Name
Name
Permit Number or Address
Date

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FEDERAL FISH AND WILDLIFE PERMIT REPORT
Paperwork Reduction Act, Privacy Act, and Freedom of Information 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:
1.

The gathering of information on fish and wildlife is authorized by:
(Authorizing statutes can be found at: http://www.gpoaccess.gov/cfr/index.html and http://www.fws.gov/permits/ltr/ltr.shtml.)
a.
b.
c.
d.
e.

Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;
Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;
General Provisions, 50 CFR 10;
General Permit Procedures, 50 CFR 13; and
Wildlife Provisions (Import/export/transport), 50 CFR 14.

2.

Information requested in this form is purely voluntary. However, submission of requested information is a condition of your permit under the above
laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to revoke your permit. Response is
not required unless a currently valid Office of Management and Budget (OMB) control number is displayed on form.

3.

Disclosures outside the Department of the Interior may be made without the consent of an individual under the routine uses listed below, if the disclosure is
compatible with the purposes for which the record was collected. (Ref. 68 FR 52611, September 4, 2003)
a.
b.
c.

d.
e.

f.
g.
h.

Routine disclosure to subject matter experts, and Federal, tribal, State, 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.
Routine disclosure to Federal, tribal, 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.
Routine disclosure to Federal, tribal, 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.
Routine disclosure 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.
Routine disclosure to the appropriate Federal, tribal, State, 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.
Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.
Routine disclosure to the General Accounting Office or Congress when the information is required for the evaluation of the permit programs.
Routine disclosure 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 for which a permit is requested. The relevant
burden for a Rehabilitation permit annual report is 3 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 non-confidential 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)].