Form 3-154a Part I - Certification

OMB Control No. 1018-0007
Expiration Date: XX/XX/XXXX

UNITED STATES
DEPARTMENT OF THE INTERIOR
Fish and Wildlife Service
Wildlife and Sport Fish Restoration Program

PART I - CERTIFICATION
A. Hunting License Holders
I certify that ____________________________________________ had
(enter name of State, territory, or District of Columbia)

________________ paid hunting license holders during the license year ending
(enter total number)

________________. I certify this information as per the Federal Aid in Wildlife
(mm/dd/yyyy)

Restoration Act, as amended (50 Stat. 917; 16 U.S.C. Sec. 669 et seq.), and the
regulations of the Secretary of the Interior.
B. Sport Fishing License Holders
I certify that ____________________________________________ had
(enter name of State, territory, or District of Columbia)

________________ paid fishing license holders during the license year ending
(enter total number)

________________. I certify this information as per the Federal Aid in Sport
(mm/dd/yyyy)

Fish Restoration Act, as amended (50 Stat. 917; 16 U.S.C. Sec. 777 et seq.
except 777e-1), and the regulations of the Secretary of the Interior.

________________________________
(Signature)

__________________
(Date)

________________________________
(Title)

We are disclosing the following according to the Paperwork Reduction Act of 1995 (44 U.S.C. 3501) and the Privacy Act of 1974 (U.S.C. 552):
The Federal Aid in Wildlife Restoration Act (16 U.S.C. 669 et seq.) and Federal Aid in Sport Fish Restoration Act (16 U.S.C. 777 et seq. except 777e-1)
authorize us to collect this information. We use this information to apportion funds using the formula in the each Act. You must complete this form to obtain
benefits. See Title 50 CFR part 80 subpart D, for additional guidance. Once submitted, this form becomes public information and is not protected under the
Privacy Act.
We estimate that the public reporting burden for this form averages 12 hours per response. Our estimate includes time for gathering information, and for
completing, reviewing and signing the form. You may send your comments about this form to the Service Information Collection Clearance Officer, U.S. Fish
and Wildlife Service, MS 222-ARLSQ, 1849 C Street, NW, Washington, DC 20240.
Federal agencies may not conduct or sponsor and you are not required to respond to an information collection unless it displays a currently valid OMB control
number. The Office of Management and Budget has reviewed this information collection and assigned OMB Control No. 1018-0007.

FWS Form 3-154a
(Revised 10/09)