Form 3-202-22-2133 ANNUAL REPORT - 50 CFR 21.32 - ABATEMENT

OMB Control No. 1018-XXXX

Expires: XX/XX/XXXX

Office Use Only

Date Completed Report received: ______/______/______

Initials: ________

ANNUAL REPORT

50 CFR 21.32 - ABATEMENT

INSTRUCTIONS. You must submit an annual report if you held an Abatement permit for all or part of the previous calendar year. Complete this reporting form and return it to your Regional Migratory Bird Permit office by

January 31. Use of this form is not mandatory, but you must submit the information requested.

Complete Sections A, B, and C, and SIGN AND DATE THE CERTIFICATION STATEMENT AT THE END OF THE SUMMARY. Send the completed report to your Regional Migratory Bird Permit Office. The addresses for the offices are listed at the end of this form.

You may copy and complete any page if you need to report additional information.

ANNUAL REPORT

50 CFR 21.32 - ABATEMENT

REPORT FOR CALENDAR YEAR ________.

A. Your subpermittees.

Subpermittee Name	Address	State Falconry Permit Number

ANNUAL REPORT

50 CFR 21.32 - ABATEMENT

B. Your abatement activities.

County and State in which you or your Subpermittees Conducted Abatement	Landowner or Business Owner Name and Address	Crop or Property Protected

ANNUAL REPORT

50 CFR 21.32 - ABATEMENT

C. Raptors held under your Abatement permit.

Species	Seamless Band Number	Address Where Held	Held on December 31
			 Yes  No
			 Yes  No
			 Yes  No
			 Yes  No
			 Yes  No
			 Yes  No
			 Yes  No
			 Yes  No
			 Yes  No
			 Yes  No
			 Yes  No

CERTIFICATION STATEMENT

Your Name: __________________________________________________________________

Your Address: ______________________________________________________________________________________________

Your Federal Abatement Permit Number: _____________________________________

Your Telephone Number: ____________________________________________

Your Email Address: _________________________________________________

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: _________________________________

Sign in blue ink. No photocopied or stamped signatures.

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 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, 50 CFR 10; General Permit Procedures, 50 CFR 13; and Wildlife Provisions (Import/export/transport), 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 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, 4 September 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 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, financial data, and personal identifiers (social security number, birth date, etc.) will be removed prior to any release of the application.

5. We estimate that it will take you approximately 1 hour to complete the annual report. 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 BPHC, 5275 Leesburg Pike, Falls Church, VA 22041–3830.

Freedom of Information Act Notice

For organizations, businesses, or individuals operating as a business (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 2.13(c)(4) and 43 CFR 2.15(d)(1)(i)].

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 3-202-22-2133

04/2015