Form 3-186a Migratory Bird Acquisition and Disposition Report

USFWS Use Only

Department of the Interior
U.S. Fish and Wildlife Service
Form 3-186A

Received in Regional
Office on

_____/______/_____

MIGRATORY BIRD ACQUISITION AND DISPOSITION REPORT

Initials:

Please see reverse for instructions
1

SPECIES:
Sex:  Male

USFWS Band Number:__________________________

 Female  Unknown

Source:  Captive-bred  Wild Microchip Number: ________________
(if applicable)

Age:  Nestling
2

 Immature

 Adult

SENDER (person transferring bird)

Year of Hatch: _________

USFWS Permit No.: ______________________________________________

Name: _____________________________________________ Date of Transfer (or other action): ___________________
Address: ____________________________________________________________________________________________
City: _______________________________________________ State:

Zip:______________________

E-Mail Address: ______________________________________________________________________________________
Permit: State Falconry FWS Raptor Propagation FWS Rehabilitation (see instructions) Other:______________
If a Transfer:

 Gift

 Sale

If Release or Loss:  Release
3

 Loan

 Escape

RECIPIENT (person acquiring bird)

Theft

 Death -- Cause of Death:

USFWS Permit No.: _______________________________________

Name: _________________________________________________________ Date of Acquisition: ___________________
Address: _____________________________________________________________________________________________
City:

State:

Zip: _______________________

E-Mail Address:_______________________________________________________________________________________
Permit Type:

 State Falconry

Type of Acquisition:  Gift
4

 FWS Raptor Propagation  Other: ________________________________________
 Purchase

 Loan

 Capture/Recapture (complete section 4)

CAPTURE OR RECAPTURE (bird taken from the wild; provide band number in Section 1)  Capture

 Recapture

For all species, County (or comparable subdivision) and State of trapping location: ___________________________________
If you captured a gyrfalcon, what color is it?
5

 Black

 White

 Unknown (Nestling)

RE-BANDING (to report the re-banding of a wild or captive-bred bird)
Old Number:
New Number:

6

 Grey

 Seamless Metal  Yellow Plastic  Black Plastic  Microchip
 Yellow Plastic

 Black Plastic

 Microchip

CERTIFICATION. I certify that the information submitted above is true and correct to the best of my knowledge.
I understand that making a false statement may subject me to the criminal penalties of 18 U.S.C. 1001.

Print name: ________________________________

__________ Phone Number (with area code): ________________________
__

Signature (in blue ink) of permittee/principal officer. (No photocopied or stamped signatures)
Form 3-186A

Rev. 12/2013

______________________
Date of signature (mm/dd/yyyy)

OMB Control No. 1018-0022; Expires

INSTRUCTIONS
1.

2.

This form is for use of holders of Federal Raptor Propagation permits and State Falconry permits. It must be completed for each
transfer, acquisition, release, loss, or rebanding of a migratory bird held under the permit. Raptor propagation permittees must submit
it to the appropriate U.S. Fish and Wildlife Service permit office within 5 days of the activity. Falconry permittees must submit it to
their state falconry permitting office within 5 days of the activity. Falconry permittees may submit the information in the electronic
database at http://permits.fws.gov/186A.
If you have
transferred a bird to another permittee (or to another permit you hold),

then you must complete sections:
1, 2, 3, and 6.

released a bird or lost a bird due to its escape, theft, or death,

1, 2, and 6.

acquired a bird from another permittee, other than a rehabilitator,

1, 2, 3, and 6.

acquired a bird from a rehabilitation permittee

1, 2, 3, and 6

captured a bird from the wild or recaptured a previously captive (banded)
bird,
re-banded a bird, either wild or captive-bred, for which the band was lost or
removed,

1, 3, 4, and 6.
1, 2, 5, and 6.

Raptor propagation permittees must retain one copy of the completed form, mail one copy to your State permit office, and mail the
original to the USFWS Migratory Bird Permit Office responsible for your State. Falconry permittees may submit the information in
the electronic database at http://permits.fws.gov/186A in lieu of sending copies to your State and FWS permit office.
USFWS
Migratory Bird Permit Office
Area of Responsibility
Region
Mailing Address
1

Hawaii, Idaho, Oregon, Washington, Pacific Island Territories

911 N.E. 11th Avenue
Portland, OR 97232-4181
(503) 872-2715

2

Arizona, New Mexico, Oklahoma, Texas

P.O. Box 709
Albuquerque, NM 87103
(505) 248-7882

3

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

5600 American Blvd. West,
Suite 990, Bloomington, MN
55437-1458
(612) 713-5436

4

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

P.O. Box 49208
Atlanta, GA 30359
(404) 679-7070

5

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

P.O. Box 779
Hadley, MA 01035-0779
(413) 253-8643

6

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

P.O. Box 25486, DFC (60154)
Denver, CO 80225-0486
(303) 236-8171

7

Alaska

1011 East Tudor Road (MS 201)

Anchorage, AK 99503
(907) 786-3693
8

2800 Cottage Way, W-2606
Sacramento, CA 95825
(916) 978-6183

California, Nevada
Notice

Privacy Act (5 U.S.C.552a): The gathering of information on fish & wildlife is authorized by the Migratory Bird Treaty Act (16 U.S.C. 703 et seq.), & Parts 13 & 21 of
Title 50 of the Code of Federal Regulations. Disclosure of the requested information is necessary for administration of permits under MBTA & is a condition of your
permit. Failure to disclose all of the requested information may be sufficient cause for revocation of your permit. The information will be used to monitor disposition of
captive birds & the take of birds from the wild. If the information indicates a violation of a statute, regulation, rule, order, or license, whether civil, criminal, or regulatory in
nature, the information may be transferred to the appropriate Federal, State, local, or foreign agency charged with investigating or prosecuting such violations. (Ref. 69 FR
5261, Sept 4, 2003) Paperwork Reduction Act (44 U.S.C.3501): An agency may not conduct or sponsor, & a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The public reporting burden estimate for reviewing instructions, gathering & maintaining data, &
completing this form is 15 minutes. Comments on the form, including the burden estimate, should be mailed to the Information Collection Clearance Officer (Ref 10180022), Mail Stop 222-ARLSQ, Fish &Wildlife Service, U.S. Department of the Interior, 1849 C Street, NW, Washington, D.C. 20240.