Form 3-202-19-2148 Annual Report - 50 CFR 21.48 - Depredation Order for Dou

Office Use Only

ANNUAL REPORT - 50 CFR 21.48
Depredation Order for Double-crested Cormorants
to Protect Public Resources

Date Completed Report received: ______/______/______
Initials: ________

INSTRUCTIONS. You must submit an annual report, if you conducted any Double-crested Cormorant control activities under the provisions of 50 CFR 21.48. Complete this
reporting form and return it to your Regional Migratory Bird Permit Office (see addresses below) by December 31, if you conducted control under the Public Resource
Depredation Order from October 1 of the previous year to September 30 of the current year. Use of this form is not mandatory, but you must submit the information requested.
Please summarize by location and then by date.
SIGN AND DATE THE CERTIFICATION STATEMENT AT THE END OF THE SUMMARY
REPORTING PERSON OR ORGANIZATION: _____________________________________________________________________________________________________
ADDRESS: ____________________________________________________________________________ CITY: ______________________ STATE: _____ ZIP: __________
TELEPHONE NUMBER: _______________________________

EMAIL ADDRESS: __________________________________________

Location Taken

Date Taken

Place Name

County

State

Year

Month

Day

YEARS: _________________

Number of Nests
Number of
Double-crested
Nests in
Nests
Uuntreated
Cormorants
which eggs
nests
destroyed
Killed
were oiled

Example: Beaver Islands, Whiskey Island

Charlevoix

MI

2013

5

22

287

208

56

117

Example: Thunder Bay, Rockport

Alpena

MI

2013

April

15

10

0

0

0

Totals:

Certification: I hereby certify that I have read and am familiar with the regulations contained in Title 50, Part 21.48 of the Code of Federal Regulations, and I certify that the
information submitted in this report is complete and accurate to the best of my knowledge and belief. I understand that any false statement herein may subject me to the criminal
penalties of 18 U.S.C. 1001.
Signature: ____________________________________________________________________________________________
Signature (in blue ink) and Title of individual responsible for the report information. (No photocopied or stamped signatures)
ANNUAL REPORT - 50 CFR 21.48
FWS Form 3-202-19-2148, 8/2013

Date: __________________________________
Date of signature (mm/dd/yyyy)

OMB Control No. 1018-0121, Expires XX/XX/20XX

Supplemental Sheet - Depredation Order for Double-crested Cormorants to Protect Public Resources
REPORTING PERSON OR ORGANIZATION: ______________________________________________________ YEARS: ________________ PAGE NUMBER: _____
Location Taken
Place Name

Date Taken
County

State

Year

Month

Day

Number of Nests
Number of
Double-crested
Nests in
Nests
Uuntreated
Cormorants
which eggs
destroyed
nests
Killed
were oiled

Totals:

ANNUAL REPORT - 50 CFR 21.48
FWS Form 3-202-19-2148, 8/2013

OMB Control No. 1018-0121, Expires XX/XX/20XX6

Depredation Order for Double-crested Cormorants to Protect Public Resources
REPORTING PERSON OR ORGANIZATION: ______________________________________________________ YEARS: ________________ PAGE NUMBER: _____
In addition to the number of Double-crested Cormorants killed and nests treated, you must provide the following information. Attach additional sheets as needed.
1a. Number and species of nontarget migratory birds taken:
1b. Statement of efforts being made to minimize incidental take of nontarget species:

2a. Description of the impacts or anticipated impacts to public resources (fish, wildlife, plants, and their habitats) by Double-crested Cormorants:

2b. Management objectives for the area or resource in question:

3. Description of the evidence supporting the conclusion that Double-crested Cormorants are causing or will cause public resource impacts:

4. Discussion of other limiting factors affecting the public resource (e.g., biological, environmental, and socioeconomic):

5. Discussion of how control efforts are expected to, or actually did, alleviate resource impacts:

6. If reducing or eliminating local breeding populations (a group of birds from breeding colonies that interact on a regular basis at a local scale), report on the efforts to:
a. evaluate effects of management activities on Double-crested Cormorants at the control site:

b. evaluate, by means of collecting data or using best available information, effects of management activities on the public resources being protected and on nontarget species:

FWS Form 3-202-19-2148, 8/2013

OMB Control No. 1018-0121, Expires XX/XX/20XX

FISH AND WILDLIFE SERVICE DEPREDATION ORDER ANNUAL REPORT
Paperwork Reduction Act and Privacy 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 of 50 CFR 10, and the Wildlife Provisions (Import/export/transport), 50 CFR 14. The information is maintained in
accordance with the Privacy Act System of Records: Permits System - Interior, FWS-21.
2. Information requested in this form is purely voluntary. However, submission of requested information is a condition of your operating under the depredation order and the above
laws. Failure to provide the requested information may be sufficient cause to pursue legal action against you for take of migratory birds. However, your response is not required
unless a currently valid Office of Management and Budget (OMB) control number is displayed on the 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). Among the purposes are the following, not all of which are applicable in every case.
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 General 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, and personal identifiers (if reported) will be removed prior to any release of the report.
5. The relevant burden for an annual report for activities under 50 CFR 21.48 is 20 to 95 hours, depending on whether local breeding populations are being reduced or eliminated.
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 2042-PDM, U.S. Department of the
Interior, 1849 C Street, NW, Washington D.C. 20240.

U.S. Fish and Wildlife Service
Regional Migratory Bird Permit Offices
REGION

AREA OF RESPONSIBILITY

MAILING ADDRESS
th

1

Hawaii, Idaho, Oregon, and Washington

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

2

Arizona, New Mexico, Oklahoma, and Texas

P.O. Box 709
Albuquerque, NM 87103

3

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

5600 American Boulevard West
Suite 990
Bloomington, MN 55437-1458

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

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

6

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

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

7

Alaska

1011 East Tudor Road
Mail Stop 201
Anchorage, AK 99503-6103

8

California and Nevada

2800 Cottage Way
Sacramento, CA 95825-1829

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