Form 3-202-2143 Annual Report - 50 CFR 21.43 -Depredation Order for Blac

ANNUAL REPORT - 50 CFR 21.43
DEPREDATION ORDER FOR BLACKBIRDS, COWBIRDS,
GRACKLES, CROWS, AND MAGPIES

Office Use Only
Date Completed Report received: ______/______/______
Initials: ________

INSTRUCTIONS. You must submit an annual report if you conducted any control activities under the provisions of 50 CFR 21.43. Complete this reporting form and
return it to your Regional Migratory Bird Permit Office (see addresses below) by January 31, if you conducted depredation control under the depredation order in the
previous calendar year. Use of this form is not mandatory, but you must submit the information requested. Please summarize by species and then by location.

SIGN AND DATE THE CERTIFICATION STATEMENT AT THE END OF THE SUMMARY
REPORTING PERSON OR ORGANIZATION: ____________________________________________________________________________________________________
ADDRESS: _____________________________________________________________________________________ CITY__________________ STATE _____ ZIP _______
TELEPHONE NUMBER: _____________________
Species
Collected

Number
Taken

Month Taken

EMAIL ADDRESS: __________________________________________

County and State

GPS
Coordinates1,2

Method of Take

Purpose of the Take
(Crop or Animal
Species)

REPORT FOR CALENDAR YEAR ________
Disposition of
Nontarget Species
(Released, Sent to
Rehabilitator, or Died)

Measures to Minimize
Nontarget Captures

Total:
1
2

To 3 decimal places.
GPS coordinates should not be reported for captures by the U.S. Department of Agriculture’s Animal and Plant Health Inspection Services, Wildlife Services that are conducted to
protect agriculture operations, farming, or conservation practices.

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: _______________________________________________________________
FWS Form 3-202-2143, 04/13

Date: ______________________________________
OMB Control No. 1018-0146, Expires XX/XX/XXXX

ANNUAL REPORT - 50 CFR 21.43
DEPREDATION ORDER FOR BLACKBIRDS, COWBIRDS, GRACKLES, CROWS, AND MAGPIES
NAME/ORGANIZATION: ____________________________________________________ REPORT YEAR: __________ PAGE NO. _____
Species
Collected

Number
Taken

Month Taken

County and State

GPS
Coordinates1,2

Method of Take

Purpose of the Take
(Crop or Animal
Species)

Disposition of
Nontarget Species
(Released, Sent to
Rehabilitator, or Died)

Measures to Minimize
Nontarget Captures

Total:

FWS Form 3-202-2143, 04/13

OMB Control No. 1018-0146, Expires XX/XX/XXXX

FISH AND WILDLIFE SERVICE DEPREDATION ORDER ANNUAL REPORT
Paperwork Reduction Act and Privacy 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 of
the following.
1. The gathering of information on fish and wildlife is authorized by the Bald and Golden Eagle Protection Act (16 U.S.C. 668); 50 CFR 22, the Migratory Bird Treaty Act
(16 U.S.C. 703-712), 50 CFR 21; General Provisions of 50 CFR 10, and the Wildlife Provisions (Import/export/transport) of 50 CFR 14. You can find the authorizing statutes
at: http://www.gpoaccess.gov/cfr/index.html and http://www.fws.gov/permits/ltr/ltr.shtml.
2. Information requested in this form is purely voluntary. However, submission of requested information is a condition of your operating under the depredation order and
the above laws. Failure to provide the requested information may be sufficient cause to pursue legal action against you for take of migratory birds. However, your
response is not required unless a currently valid Office of Management and Budget (OMB) control number is displayed on the 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, 4 September 2003). Among the purposes are the following, not all of which are
applicable in every case.
a. 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.
b. 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.
c. 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.
d. 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.
e. 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.
f. Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.
g. Routine disclosure to the General Accounting Office or Congress when the information is required for the evaluation of the permit programs.
h. 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, and personal identifiers (if reported) will be removed prior to any release of the
report.
5. The relevant burden for an annual report for activities under 50 CFR 21.43 is 2.5 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 2042-PDM, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.

U.S. Fish and Wildlife Service
Regional Migratory Bird Permit Offices
REGION

AREA OF RESPONSIBILITY

MAILING ADDRESS

1

Hawaii, Idaho, Oregon, and Washington

911 N.E. 11th Avenue
Portland, OR 97232-4181

2

Arizona, New Mexico, Oklahoma, and Texas

P.O. Box 709
Albuquerque, NM 87103

3

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

5600 America Boulevard
West
Suite 990
Bloomington, MN 554371458

4

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

P.O. Box 49208
Atlanta, GA 30359

5

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

P.O. Box 779
Hadley, MA 01035-0779

6

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

P.O. Box 25486 DFC (60154)
Denver, CO 80225-0486

7

Alaska

1011 East Tudor Road
Mail Stop 201
Anchorage, AK 99503-6103

8

California and Nevada

2800 Cottage Way
Sacramento, CA 958251829

CONTACT INFORMATION
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Fax: (413) 253-8424
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Fax: (303) 236-8017
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Fax: (907) 786-3641
Email:
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Tel: (916) 978-6183
Fax: (916) 414-6486
Email:
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