Form 3-202-6 Special Purpose - Game Bird - Annual Report

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
Return to: U.S. Fish and Wildlife Service (USFWS)

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

or

SPECIAL PURPOSE – GAME BIRD - 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: Please provide (type or print) the information requested below for all birds held under your permit during the report year, 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, including a signed certification statement. A supplemental sheet is available if needed. Filing an
annual report is a condition of your permits. Failure to file a timely report could result in suspension of your permit. You must submit a report even if you had no activity during the report year.
(Ref. 50 CFR parts 13 & 21)
**Method of Marking Code: R=Remove hind toe of right foot; W=Pinion one wing; B=Band one leg with a seamless leg band; T=Tattoo web of one foot.
MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT.
Method of
Number
Number
Total
SPECIES
Total Number
Number
Number
Number that
Marking (See
Sold or
Released
Number at
(Common Name)
at Start of Year
Raised
Acquired
Died
codes above)
Traded
To Wild
End of Year

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 (in blue ink) of permittee/principal officer. (No photocopied or tamped signatures)
Form 3-202-6
Rev 12/2013

Date of signature (mm/dd/yyyy)
OMB Control No. 1018-0022 Expires xx/xx/2017

SUPPLEMENTAL SHEET - SPECIAL PURPOSE - GAME BIRD PROPAGATION ANNUAL REPORT
PERMITTEE:

PERMIT NUMBER:
SPECIES
(Common Name)

Form 3-202-6

Rev 12/2013

Total Number
at Start of Year

Method of
Marking (See
codes above)

REPORT YEAR:_________ SUPPLEMENTAL PAGE NO: ______
Number
Raised

Number
Acquired

Number
Sold or
Traded

Number that
Died

Number
Released
To Wild

OMB No. 1018-0022

Total
Number at
End of Year

Expires xx /xx/2017

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.html.)
a. Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;
b. Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;
c. General Provisions, 50 CFR 10;
d. General Permit Procedures, 50 CFR 13; and
e. 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. 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 an 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, 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 Special Purpose – Game Bird
permit annual report is 30 minutes. 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 non-confidential summary and remaining documents may be
made available to the public under FOIA [43 CFR 2.26 – 2.33].

Migratory Bird Regional Permit
Offices
FWS
REGION

AREA OF
RESPONSIBILITY

MAILING
ADDRESS

Region 1

Hawaii, Idaho, Oregon, Washington

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

Region 2

Arizona, New Mexico, Oklahoma, Texas

P.O. Box 709
Albuquerque, NM 87103

Region 3

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

5600 American Blvd. West, Suite 990
Bloomington, MN
55437-1458
(Effective 5/31/2011)

Tel. (612) 713-5436
Fax (612) 713-5393
Email [email protected]

Region 4

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

P.O. Box 49208
Atlanta, GA 30359

Tel. (404) 679-7070
Fax (404) 679-4180
Email [email protected]

Region 5

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

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

Tel. (413) 253-8643
Fax (413) 253-8424
Email [email protected]

Region 6

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

Region 7

Alaska

Region 8

California, Nevada

P.O. Box 25486
DFC(60154)
Denver, CO 80225-0486
1011 E. Tudor Road
(MS-201)
Anchorage, AK 99503
2800 Cottage Way
Room W-2606
Sacramento, CA 95825

Tel. (303) 236-8171
Fax (303) 236-8017
Email [email protected]
Tel. (907) 786-3693
Fax (907) 786-3641
Email [email protected]
Tel. (916) 978-6183
Fax (916) 414-6486
[email protected]

CONTACT INFORMATION
Tel. (503) 872-2715
Fax (503) 231-2019
Email [email protected]
Tel. (505) 248-7882
Fax (505) 248-7885
Email [email protected]