Form 3-202-16 Eagle Nest Take Report

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

EAGLE NEST TAKE (50 CFR 22.27) - REPORT
PERMITTEE: ___________________________
ADDRESS: ______

__________

_____

______________________________________

___________________________________________________ __
City

State

PERMIT NUMBER:___________

__________

REPORT FOR CALENDAR YEAR*: ______________
*Programmatic take only
REPORT DUE DATE: ___________________________

Zip Code

 Check here if reporting a change of name, address, or contact information PHONE: _______________________ Email: _____ ___________________
INSTRUCTIONS: Complete all sections in the space provided or numbered accordingly to the questions below on a separate sheet of paper 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. Filing an
annual report is a condition of your permit. You must submit a report even if you had no activity during the year. MAKE SURE YOU SIGN & DATE THE
CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT. (Ref. 50 CFR parts 13 & 21)
1.  Bald Eagle Nest Take
 Golden Eagle Nest Take
2. Did (does) the permit authorize take of a specific nest or nests?
 Yes.
 No, the permit authorizes programmatic nest take.
3. Provide the following information for each authorized nest take. If more than one nest was taken, please complete a supplemental page for each nest.
A. Date the authorized nest take occurred: ____ /____/_______
B. Location of the nest that was taken: _________________________________________________________________________________________
C. If the nest was active, disposition of chicks and eggs (e.g., name and contact information of permitted rehabilitator, State agency, or USFWS):
_______________________________________________________________________________________________________________________
D. Disposition of the nest. Check all that apply: Removed
 Destroyed
 Relocated
 Donated to a permitted recipient  Substitute nest provided
a. Have eagles rebuilt and if so, are they breeding and fledging young?
 Yes  No
b. If nest was relocated or a substitute nest provided, are adult eagles tending the new nest? Yes No  No, but nest removal was conducted outside eagle
breeding season  Do not know Not applicable.
c. If nest was relocated or a substitute nest provided, provide location:_______________________________________________________________
d. If nest was relocated, please attach a description of methods and techniques employed to move it.
4. Describe the mitigation measures you are implementing to offset the nest take and/or minimize the need for future nest take.
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 stamped signatures)

Form 3-202-16 (Rev 12/013)

Date of signature (mm/dd/yyyy)

OMB Control No. 1018-0022

Expires xx/xx2017

EAGLE NEST TAKE REPORT

SUPPLEMENTAL SHEET
REPORT DATE ____________

PERMITTEE:_____________________________________

PERMIT NUMBER:__________________

SUPPLEMENTAL PAGE #:____

3. Provide the following information for each authorized nest take.
A. Date the authorized nest take occurred: ____ /____/_______
B. Location of the nest that was taken: ________________________________________________________________________________________
C. Disposition of the nest: Destroyed Relocated within territory Relocated outside territory Donated to a permitted recipient
Destroyed, substitute nest provided in territory Destroyed, substitute nest provided outside territory
D. If nest was relocated or a substitute nest provided, are adult eagles tending the new nest? Yes
breeding season  Do not know.

No

No, but nest removal occurred outside the eagles

E. If nest was active, disposition of chicks and eggs (e.g., name and contact information of permitted rehabilitator, State agency, or USFWS):
______________________________________________________________________________________________________________________
4. Describe the mitigation measures you have conducted to offset the nest take. If your permit does not require mitigation, you may leave this blank.

Form 3-202-16

(Rev 12/2013)

OMB No. 1018-0022

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.
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 an Eagle Nest Take permit annual report is 16 hours
(including monitoring and recordkeeping). 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]