Form 3-186a Migratory Bird Acquisition and Disposition Report

USFWS Use Only

Department of the Interior
U.S. Fish and Wildlife Service
Form 3-186A

Received in Regional
Office on

_____/______/_____

MIGRATORY BIRD ACQUISITION AND DISPOSITION REPORT

Initials:

Please see reverse for instructions
1

2

SPECIES:
Sex:

Male

Age:

Nestling

USFWS Band Number:__________________________
Female

Unknown

Immature

Source:

Adult

SENDER (person transferring bird)

Captive-bred

Wild

Year of Hatch:

USFWS Permit No.: ______________________________________________

Name: _____________________________________________ Date of Transfer (or other action): ___________________
Address: ____________________________________________________________________________________________
City: _______________________________________________ State:

Zip:______________________

E-Mail Address: ______________________________________________________________________________________
USFWS Permit Type:
If a Transfer:

Gift

If Release or Loss:
3

Falconry

Raptor Propagation

Sale
Release

Other: ________________________________________

Loan
Escape

RECIPIENT (person acquiring bird)

Theft

Death -- Cause of Death:

USFWS Permit No.: _______________________________________

Name: _________________________________________________________ Date of Acquisition: ___________________
Address: _____________________________________________________________________________________________
City:

State:

Zip: _______________________

E-Mail Address:_______________________________________________________________________________________
USFWS Permit Type:
Type of Acquisition:
4

Falconry
Gift

Raptor Propagation
Purchase

Loan

Other: ________________________________________
Capture/Recapture (complete section 4)

CAPTURE OR RECAPTURE (bird taken from the wild; provide band number in Section 1)

Capture

Recapture

For all species, County (or comparable subdivision) and State of trapping location: ___________________________________
If you captured a gyrfalcon, what color is it?
5

6

Grey

Black

White

Unknown (Nestling)

RE-BANDING (to report the re-banding of a wild or captive-bred bird)
Old Number:

Seamless Metal

Yellow Plastic

New Number:

Yellow Plastic

Black Plastic

Black Plastic

CERTIFICATION. I certify that the information submitted above is true and correct to the best of my knowledge.
I understand that making a false statement may subject me to the criminal penalties of 18 U.S.C. 1001.
Print name: ___________________________________________ Phone Number (with area code): ________________________
Signature: _________________________________________________________ Date: _____________________________

Form 3-186A

Rev. 7/2007

OMB No. 1018-0022; Expires xxxxx

INSTRUCTIONS
1.

2.

This form must be completed for each transfer, acquisition, release, loss, or rebanding of a migratory bird held under your permit.
You must submit it to the appropriate U.S. Fish and Wildlife Service office within 5 days of the activity.

If you have
transferred a bird to another permittee (or to another permit you hold),

then you must complete sections:
1, 2, 3, and 6.

released a bird or lost a bird due to its escape, theft, or death,

1, 2, and 6.

acquired a bird from another permittee,

1, 2, 3, and 6.

captured a bird from the wild or recaptured a previously captive (banded)
bird,
re-banded a bird, either wild or captive-bred, for which the band was lost or
removed,

1, 3, 4, and 6.
1, 2, 5, and 6.

Retain one copy of the completed form, mail one copy to your State permit office, and mail the original to the U.S. Fish and Wildlife
Service Migratory Bird Permit Office responsible for your State.
USFWS
Region

Area of Responsibility

Migratory Bird Permit Office
Mailing Address

1

California, Hawaii, Idaho, Nevada, Oregon, Washington, Pacific Island
Territories

911 N.E. 11th Avenue
Portland, OR 97232-4181
(503) 872-2715

2

Arizona, New Mexico, Oklahoma, Texas

P.O. Box 709
Albuquerque, NM 87103
(505) 248-7882

3

Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Ohio, Wisconsin

One Federal Drive
Ft. Snelling, MN 55111-4056
(612) 713-5436

4

Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi,
North Carolina, South Carolina, Tennessee, Puerto Rico, Virgin Islands

P.O. Box 49208
Atlanta, GA 30359
(404) 679-7070

5

Connecticut, Delaware, District of Columbia, Maine, Maryland,
Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania,
Rhode Island, Vermont, Virginia, West Virginia

P.O. Box 779
Hadley, MA 01035-0779
(413) 253-8643

6

Colorado, Kansas, Montana, Nebraska, North Dakota, South Dakota,
Utah, Wyoming

P.O. Box 25486, DFC
Denver, CO 80225-0486
(303) 236-8171

7

Alaska

1011 East Tudor Road (MS 201)

Anchorage, AK 99503
(907) 786-3693

Notice
Privacy Act (5 U.S.C.552a): The gathering of information on fish & wildlife is authorized by the Migratory Bird Treaty Act (16 U.S.C. 703 et seq.), & Parts 13 & 21 of
Title 50 of the Code of Federal Regulations. Disclosure of the requested information is necessary for administration of permits under MBTA & is a condition of your
permit. Failure to disclose all of the requested information may be sufficient cause for revocation of your permit. The information will be used to monitor disposition of
captive birds & the take of birds from the wild. If the information indicates a violation of a statute, regulation, rule, order, or license, whether civil, criminal, or regulatory in
nature, the information may be transferred to the appropriate Federal, State, local, or foreign agency charged with investigating or prosecuting such violations. (Ref. 69 FR
5261, Sept 4, 2003) Paperwork Reduction Act (44 U.S.C.3501): An agency may not conduct or sponsor, & a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The public reporting burden estimate for reviewing instructions, gathering & maintaining data,&
completing this form is 15 minutes. Comments on the form, including the burden estimate, should be mailed to the Information Collection Clearance Officer (Ref 10180022), Mail Stop 222-ARLSQ, Fish &Wildlife Service, U.S. Department of the Interior, 1849 C Street, NW, Washington, D.C. 20240.