Form 3-202-21-2143 Annual Report - Depredation Order for Blackbirds, Grackl

Form 3-200-21-2143 (Rev. 10/2017)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0146
Expires xx/xx/xxxx

ANNUAL REPORT - 50 CFR 21.43
DEPREDATION ORDER FOR BLACKBIRDS,
GRACKLES, COWBIRDS, MAGPIES, AND CROWS

INSTRUCTIONS. You must submit an annual report if you conducted any control activities under the provisions of 50 CFR 21.43. Complete this reporting form and return it to your Regional
Migratory Bird Permit Office (see addresses below) by January 31, if you conducted depredation control under the depredation order in the previous calendar year. Use of this form is not
mandatory, but you must submit the information requested. Please summarize by species and then by location.

SIGN AND DATE THE CERTIFICATION STATEMENT AT THE END OF THE SUMMARY
REPORTING PERSON OR ORGANIZATION: __________________________________________________________________________________________________________
ADDRESS: ________________________________________________________________________________________ CITY__________________ STATE _____ ZIP _______
TELEPHONE NUMBER: _____________________
Number
Taken

Species Taken

EMAIL ADDRESS: ________________________________________________
Month Taken

County and State Where Birds
were Taken

REPORT FOR CALENDAR YEAR ________

Purpose of the Take

Disposition of non-target species
(Released, sent to rehab, etc.)

Total:

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: _____________________________________

Office Use Only
Date Completed Report received: ______/______/______
Initials: ________

Page 1 of 2

Form 3-200-21-2143 (Rev. 10/2017)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0146
Expires xx/xx/xxxx

ANNUAL REPORT - 50 CFR 21.43
SUPPLEMENTAL SHEET - DEPREDATION ORDER FOR BLACKBIRDS, GRACKLES, COWBIRDS, MAGPIES, AND CROWS
NAME/ORGANIZATION: ________________________________________________________________________________ REPORT YEAR: __________ PAGE NO. _____
Number
Taken

Species Taken

Month Taken

County and State
Where birds Were Taken

Purpose of the Take
(Crop or Animal Species)

Total:

Page 2 of 2

Form 3-200-21-2143 (Rev. 10/2017)
U.S. Fish and Wildlife Service

OMB Control No. 1018-0146
Expires xx/xx/xxxx

FISH AND WILDLIFE SERVICE DEPREDATION ORDER ANNUAL REPORT
NOTICES
PRIVACY ACT STATEMENT
Authority: The gathering of information on fish and wildlife is authorized by the Bald and Golden 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 of 50 CFR 14.
Purpose: To verify the reporting person or organization has an eligible permit to conduct depredation control activities in accordance with the Depredation Order for
Blackbirds, Cowbirds, Grackles, Crows and Magpies.
Routine Uses: The individual or organization’s contact information may be used to verify permit status, provide permittees with permit-related information, and monitor
activities conducted under a permit. More information about routine uses can be found in the System of Records Notice, Permits System, FWS-21.
Disclosure: Contact information requested in this form is voluntary. However, submission of the requested information is a condition of operating under the depredation
order and the laws listed in the Authority. Failure to provide the requested contact information may be sufficient cause to pursue legal action against you or the
organization’s take of migratory birds.
PAPERWORK REDUCTION ACT STATEMENT
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to help the service monitor and assess the impact of the depredation orders on
blackbird, cowbird, crow, grackle, and magpie populations, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Submission
of the information requested in this form is required to obtain or retain a benefit and 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. According to the Paperwork Reduction Act of
1995, an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.
OMB has approved this information collection and assigned control number 1018-0146.
ESTIMATED BURDEN STATEMENT
We estimate the relevant public reporting burden for an annual report for activities under 50 CFR 21.43 is 2 hours for reporting and 2 hours for recordkeeping for a total of 4
hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to the Service Information Collection Clearance Officer, Division of Policy, Performance, and Management Programs, Fish and Wildlife Service, Mail Stop BPHC, 5275
Leesburg Pike, Falls Church, VA 22041-3803. Please do not send your completed form to this address.

OMB Control No. 1018-0146
Expires xx/xx/xxxx

Form 3-200-21-2143 (Rev. 10/2017)
U.S. Fish and Wildlife Service

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

AREA OF RESPONSIBILITY

1

Hawaii, Idaho, Oregon, and Washington

2

Arizona, New Mexico, Oklahoma, and Texas

3

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

4
5

Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina,
South Carolina, Tennessee, Virgin Islands, and Puerto Rico
Connecticut, District of Columbia, Delaware, Maine, Maryland, Massachusetts, New Hampshire,
New Jersey, New York, Pennsylvania, Rhode Island, Virginia, Vermont, and West Virginia

6

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

7

Alaska

8

California and Nevada

MAILING ADDRESS
th
911 N.E. 11 Avenue
Portland, OR 97232-4181
P.O. Box 709
Albuquerque, NM 87103
5600 America Boulevard West
Suite 990
Bloomington, MN 55437-1458
1875 Century Blvd., NE
Atlanta, GA 30345
P.O. Box 779
Hadley, MA 01035-0779
P.O. Box 25486 DFC (60154)
Denver, CO 80225-0486
1011 East Tudor Road
Mail Stop 201
Anchorage, AK 99503-6103
2800 Cottage Way
Sacramento, CA 95825-1829

CONTACT INFORMATION
Tel: (503) 872-2715
Email: [email protected]
Tel: (505) 248-7882
Email: [email protected]
Tel: (612) 713-5436
Email: [email protected]
Tel: (404) 679-7070
Email: [email protected]
Tel: (413) 253-8643
Email: [email protected]
Tel: (303) 236-8171
Email: [email protected]
Tel: (907) 786-3693
Email: [email protected]
Tel: (916) 978-6183
Email: [email protected]