Form 3-202-21-2143 Annual Report - Depredation Order for Blackbirds, Grackl

Office Use Only

Date Completed Report received: ______/______/______

Initials: ________

ANNUAL REPORT - 50 CFR 21.43

DEPREDATION ORDER FOR BLACKBIRDS,

GRACKLES, COWBIRDS, MAGPIES, AND CROWS

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: _____________________ EMAIL ADDRESS: ________________________________________________ REPORT FOR CALENDAR YEAR ________

Species Taken	Number Taken	Month Taken	County and State Where Birds were Taken	Purpose of the Take (Crop or Animal Species)
Total:

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: ______________________________________

ANNUAL REPORT - 50 CFR 21.43

SUPPLEMENTAL SHEET - DEPREDATION ORDER FOR BLACKBIRDS, GRACKLES, COWBIRDS, GRACKLES, MAGPIES, AND CROWS

NAME/ORGANIZATION: ________________________________________________________________________________ REPORT YEAR: __________ PAGE NO. _____

Species Taken	Number Taken	Month Taken	County and State Where birds Were Taken	Purpose of the Take (Crop or Animal Species)
Total:

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 Government Accountability 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 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	CONTACT INFORMATION
1	Hawaii, Idaho, Oregon, and Washington	911 N.E. 11th Avenue Portland, OR 97232-4181	Tel: (503) 872-2715 Fax: (503) 231-2019 Email: [email protected]
2	Arizona, New Mexico, Oklahoma, and Texas	P.O. Box 709 Albuquerque, NM 87103	Tel: (505) 248-7882 Fax: (505) 248-7885 Email: [email protected]
3	Iowa, Illinois, Indiana, Minnesota, Missouri, Michigan, Ohio, and Wisconsin	5600 America Boulevard West Suite 990 Bloomington, MN 55437-1458	Tel: (612) 713-5436 Fax: (612) 713-5393 Email: [email protected]
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	Tel: (404) 679-7070 Fax: (404) 679-4180 Email: [email protected]
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	Tel: (413) 253-8643 Fax: (413) 253-8424 Email: [email protected]
6	Colorado, Kansas, Montana, North Dakota, Nebraska, South Dakota, Utah, and Wyoming	P.O. Box 25486 DFC (60154) Denver, CO 80225-0486	Tel: (303) 236-8171 Fax: (303) 236-8017 Email: [email protected]
7	Alaska	1011 East Tudor Road Mail Stop 201 Anchorage, AK 99503-6103	Tel: (907) 786-3693 Fax: (907) 786-3641 Email: [email protected]
8	California and Nevada	2800 Cottage Way Sacramento, CA 95825-1829	Tel: (916) 978-6183 Fax: (916) 414-6486 Email: [email protected]

FWS Form 3-202-21-2143, 09/13 OMB Control No. 1018-0146, Expires XX/XX/XXXX