Form 3-202-16 Eagle Nest Take and Monitoring Report

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
(See attached addresses)
EAGLE NEST TAKE (50 CFR 22.27) - REPORT
PERMITTEE: __________________________________________

PERMIT UMBER:_______________________________

ADDRESS: ____________________________________________

REPORT FOR CALENDAR YEAR*: _______________
*Programmatic take only
REPORT DUE DATE: ____________________________

_______________________________________________________
City

State

Zip Code

 Check here if reporting a change of name, address, or contact information
PHONE: ___________________________ Email: __________________________
INSTRUCTIONS: Complete all sections and return the completed report to the above address by the due date. Filing an annual report is a condition of your permit.
You must submit a report even if you had no activity during the year. MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW
BEFORE YOU SUBMIT YOUR REPORT. (Ref. 50 CFR parts 13 & 21)
1.  Bald Eagle Nest Take

 Golden Eagle Nest Take

2. Did (does) the permit authorize take of a specific nest or nests?

 Yes.

 No, the permit authorizes programmatic nest take.

3. Provide the following information for each authorized nest take. If more than one nest was taken, please complete a supplemental page for each nest.
A. Date the authorized nest take occurred: ____ /____/_______
B. Location of the nest that was taken: _________________________________________________________________________________________
C. If the nest was active, disposition of chicks and eggs (e.g., name and contact information of permitted rehabilitator, State agency, or USFWS):
_______________________________________________________________________________________________________________________
D. Disposition of the nest. Check all that apply:
Removed
Destroyed
Relocated

 Donated to a permitted recipient

 Substitute nest provided

a. If nest was relocated or a substitute nest provided, are adult eagles tending the new nest? ____Yes
outside eagle breeding season ____ Do not know ____ Not applicable.

____No

____No, but nest removal was conducted

b. If nest was relocated or a substitute nest provided, provide location:_______________________________________________________________
c. If nest was relocated, please attach a description of methods and techniques employed to move it.
4. Describe the mitigation measures you are implementing to offset the nest take and/or minimize the need for future nest take.

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: ____________________________________
Form 3-202-16 (Rev 9/2010)

OMB No. 1018-0022

Expires x/xx/xxxx

EAGLE NEST TAKE REPORT

SUPPLEMENTAL SHEET
REPORT DATE ____________

PERMITTEE:_____________________________________

PERMIT NUMBER:__________________

SUPPLEMENTAL PAGE #:____

3. Provide the following information for each authorized nest take.
A. Date the authorized nest take occurred: ____ /____/_______
B. Location of the nest that was taken: ________________________________________________________________________________________
C. Disposition of the nest: ____Destroyed ____Relocated within territory ____Relocated outside territory ____Donated to a permitted recipient
____Destroyed, substitute nest provided in territory ____Destroyed, substitute nest provided outside territory
D. If nest was relocated or a substitute nest provided, are adult eagles tending the new nest? ____Yes
eagles breeding season ____ Do not know.

____No

____No, but nest removal occurred outside the

E. If nest was active, disposition of chicks and eggs (e.g., name and contact information of permitted rehabilitator, State agency, or USFWS):
______________________________________________________________________________________________________________________
4. Describe the mitigation measures you have conducted to offset the nest take. If your permit does not require mitigation, you may leave this blank.

Form 3-202-16

(rev 9/2010)

OMB No. 1018-xxxx

Expires x/xx/xxxx

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 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 infrmation.
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 an Eagle Nest Take
permit annual report is 16 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)].