Form 3-202-10 Special State Canada Goose Permit - Annual Report

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
(See attached addresses)

Office Use Only
Date Completed Report
rec’d in Regional Office
______/_____/_______
Initials: ________

SPECIAL STATE CANADA GOOSE PERMIT - ANNUAL REPORT
PERMITTEE: ____________________________________________________________

PERMIT NUMBER:_________________________

ADDRESS: _______________________________________________________________

REPORT FOR CALENDAR YEAR: _______________

_______________________________________________________________

REPORT DUE DATE: ___________________________

City

State

Zip Code

___ Check here if reporting a change of name, address, or contact information
PHONE: ______________________ Email: __________________________________________
INSTRUCTIONS: Type or print the information requested below for all birds taken or held under your permit during the year covered by this report and return the completed report to the above
address by the due date. Use of this form is not mandatory, but the same information must be submitted. A supplemental sheet is available if needed. Filing an annual report is a condition of your
permit. Failure to file a timely report can result in permit suspension. If you had no activity under your permit during the report year, state “No activity” on the form. (50 CFR parts 13 & 21)
MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT.
A. Non-lethal Measures - Describe the non-lethal techniques utilized:

B.

Quantity
Month Taken

* Relocated in the wild

Location
(County or equivalent)

Birds
Killed

Final Disposition

Nests
(What you did with the birds, eggs, carcasses,
Birds
Destroyed
e.g., buried; incinerated; euthanized & donated)
Relocated*
**

* * Refers to nests with eggs that are destroyed, addled, oiled, or removed from wild. Do not enter individual eggs, and do not include inactive nests destroyed.

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.
Date: ________________________________________________________

Signature:
Form 3-202-10

Rev 9/2010

OMB No. 1018-0022

Expires x/xxxxxx

SUPPLEMENTAL SHEET - SPECIAL STATE CANADA GOOSE PERMIT ANNUAL REPORT
PERMIT NUMBER:

PERMITTEE:

REPORT YEAR: _________

B.
Location
(County or equivalent)

Month Taken

* Relocated in the wild
Form 3-202-10

SUPPLEMENTAL PAGE NO: ____

Quantity

Rev 9/2010

Birds
Killed

Final Disposition

Nests
(What you did with the birds, eggs, carcasses,
Birds
Destroyed
Relocated*
e.g.,
buried; incinerated; euthanized & donated)
**

* * Includes nests where eggs were destroyed, addled, oiled, or removed from wild.
OMB No. 1018-0022

Expires x/xxxxxx

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 We may not conduct or sponsor and you are not required to respond to a
collection of information unless it displays a currently valid OMB control number. OMB has approved this report and assigned OMB Control No. 1018-0022.

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 information.
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 Special Canada
Goose permit annual report is 1 hour. 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)].