Form 3-202-9 Depredation - Annual Report

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE

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

Return to: U.S. Fish and Wildlife Service (USFWS)
or

DEPREDATION - 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, including a signed certification statement. 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, & 22)
MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT.
►►►Please group your entries first by Species, then by State, County, and Month. Provide a subtotal for each species collected by State. See example below.
When & Where Taken
Species
(Common Name)
Example: Ring-billed Gull
Ring-billed Gull
Species Total

Quantity

State

County (or equivalent)

Month
Taken

Birds
Killed

VA
VA
VA

Fairfax
Chester
-

Mar
Apr
-

10
5
15

Active
Birds
Nests
Relocated
Destroyed
*
**
0
0
0
20
0
20

Final Disposition
(What you did with the birds, eggs, carcasses: buried,
incinerated, transferred (specify to whom), released, or
other (specify))
buried
buried
-

* Relocated in the wild ** Refers to nests with eggs that are destroyed, addled (oiled, shaken), or removed from wild. Do not enter individual eggs & do not include inactive nests (nests
without eggs) 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.
___________________________________________________________
Form 3-202-9

Signature (in blue ink) of permittee/principal officer. (No photocopied or stamped signatures)
Rev 12/2013

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

Expires xx/xx/xxxx

PERMITTEE:

PERMIT NUMBER:

Species
(Common Name)

State

REPORT YEAR: _________

When & Where Taken

Quantity

County (or equivalent)

Active
Birds
Nests
Relocated
Destroyed
*
**

Month
Taken

Birds
Killed

SUPPLEMENTAL PAGE NO: ____

Final Disposition
(What you did with the birds, eggs, carcasses: buried,
incinerated, transferred (specify to whom), released, or
other (specify))

* Relocated in the wild ** Refers to nests with eggs that are destroyed, addled (oiled/shaken) or removed from wild. Do not enter individual eggs & do not include inactive nests (nests
without eggs) destroyed.
Form 3-202-9

Rev 12/2013

OMB Control No. 1018-0022

Expires xx/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.html)
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. 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.
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 an 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 Government Accountability 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 the application.
5. The public reporting burden for information collection varies depending on the type of permit held. The relevant burden for a Depredation 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 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)

Region 4

Region 5

Alabama, Arkansas, Florida, Georgia,
Kentucky, Louisiana, Mississippi, North
Carolina, South Carolina, Tennessee, Virgin
Islands, Puerto Rico
Connecticut, District of Columbia, Delaware,
Maine, Maryland, Massachusetts, New
Hampshire, New Jersey, New York,
Pennsylvania, Rhode Island, Virginia,
Vermont, West Virginia

P.O. Box 49208
Atlanta, GA 30359

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

CONTACT INFORMATION
Tel. (503) 872-2715
Fax (503) 231-2019
Email [email protected]
Tel. (505) 248-7882
Fax (505) 248-7885
Email [email protected]
Tel. (612) 713-5436
Fax (612) 713-5393
Email [email protected]
Tel. (404) 679-7070
Fax (404) 679-4180
Email [email protected]
Tel. (413) 253-8643
Fax (413) 253-8424
Email [email protected]

Region 6

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

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

Tel. (303) 236-8171
Fax (303) 236-8017
Email [email protected]

Region 7

Alaska

1011 E. Tudor Road
(MS-201)
Anchorage, AK 99503

Tel. (907) 786-3693
Fax (907) 786-3641
Email [email protected]

Region 8

California, Nevada

2800 Cottage Way
Room W-2606
Sacramento, CA 95825

Tel. (916) 978-6183
Fax (916) 414-6486
[email protected]