Form 3-202-15 Eagle Take Annual Report

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
EAGLE TAKE (§ 22.26) - ANNUAL REPORT
PERMITTEE: _____________________________________
ADDRESS: _______________________________________
__________________________________________________

PERMIT NUMBER: ________________________
REPORT FOR CALENDAR YEAR*: _________
REPORT DUE DATE: ______________________

City

PHONE: (______)_______-____________
Email: __________________________________________

State

Zip Code

9 Check here if reporting a change of name, address, or contact inform

INSTRUCTIONS: Type or print the information requested below for each Important Eagle-Use Area (IEUA) 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 and accurate report can result
in permit suspension. Please note that the absence of eagles from an IEUA 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 IEUA identified on your permit.
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 IEUA is identified on your permit, designate which nest (or roost or foraging area) data applies to.
P – perched
DESCRIPTION OF HUMAN ACTIVITY
OBSERVED
DATE
NUMBER OF EAGLES
F – feeding
AT TIME EAGLES WERE OBSERVED
TIME
BEHAVIOR
N – sitting on or
EAGLES OBSERVED
OBSERVED
(e.g., surveying; excavation; pile driving; interior work, etc.)
OF DAY
attending nest
(If in large numbers, please estimate)

IF– in flight

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. 1001.
Signature:
Date:
OMB No. 1018-xxxx Expires x/xx/xxxx

Form 3-202-15

SUPPLEMENTAL SHEET
EAGLE TAKE ANNUAL REPORT

REPORT YEAR__________

SUPPLEMENTAL PAGE #:____

PERMITTEE:__________________________________

PERMIT NUMBER:__________________

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, 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”

FWS FORM 3-202-15

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 § 22.26 Eagle Take
permit annual report is 30 hours (including monitoring). 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 nonconfidential 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)].