Form 3-202-11 Eagle Depredation - Annual Report

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

Office Use Only
Date Completed Report
rec’d in Regional Office
______/_____/_______
Initials: ________

Click here for addresses.

EAGLE DEPREDATION - ANNUAL REPORT
PERMITTEE: ____________________________________________________________

PERMIT NUMBER:_________________________

ADDRESS: _______________________________________________________________

REPORT FOR CALENDAR YEAR: _______________

________________________________ __________ __________________

REPORT DUE DATE: ___________________________

City

State

Zip Code

 Check here if reporting a change of name, address, or contact information

PHONE: ___________________________ Email: _____________________________________
INSTRUCTIONS: Please provide (type or print) the information requested below for all activities conducted under your permit during the report year, 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. A
supplemental sheet is available if needed. Filing an annual report is a condition of your permit. Failure to file a timely report could result in suspension of your permit. You must
submit a report even if you had no activity during the year (Ref. 50 CFR parts 13, 21 & 22). Please make sure you sign and date the certification below before submitting your
report.
Number of Birds
Species
(Common Name)

State

Location
County

Month
Taken

Killed

Trapped

Hazed

Numbers of
Eggs
Nests
Taken
Affected

Final Disposition
(What you did with the birds, eggs, carcasses, e.g.,
destroyed, released to wild, transferred (specify to
whom))

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 of permittee/principal officer. (No photocopied or stamped signatures)
Form 3-202-11
Rev 4/2017

Date of signature (mm/dd/yyyy)
OMB Control No. 1018-0022 Expires XX/XX/XXXX

SUPPLEMENTAL SHEET - EAGLE DEPREDATION PERMIT - ANNUAL REPORT
PERMITTEE:

PERMIT NUMBER:

REPORT YEAR:
Number of Birds

Species
(Common Name)

Form 3-202-11

State

Rev 4/2017

Location
County

Month
Taken

Killed

Trapped

Hazed

SUPPLEMENTAL PAGE NO: ______

Numbers of
Eggs
Nests
Taken Affected

Final Disposition
(What you did with the birds, eggs, carcasses, e.g.,
destroyed, released to wild, transferred (specify to
whom))

OMB Control No. 1018-0022

Expires XX/XX/XXXX

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: www.ecfr.gov and https://www.fws.gov/birds/policies-and-regulations/permits/permit-policies-and-regulations.php)
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 Depredation permit annual report is 1 hour. 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, 5275 Leesburg Pike, MS: BPHC, Falls Church, VA 22041-3803.

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

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

AREA OF
RESPONSIBILITY
Hawaii, Idaho, Oregon,
Washington
Arizona, New
Mexico, Oklahoma,
Texas

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

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

Region 7

Alaska

Region 8

California, Nevada

MAILING
ADDRESS

CONTACT
INFORMATION

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

Tel. (503) 872-2715
Email [email protected]

P.O. Box 709
Albuquerque, NM 87103

Tel. (505) 248-7882
Email [email protected]

5600 American Blvd. West
Suite 990
Bloomington, MN
55437-1458

Tel. (612) 713-5436
Email [email protected]

1875 Century Blvd., NE
Atlanta, GA 30345

Tel. (404) 679-7070
Email [email protected]

300 Westgate Center Drive
Hadley, MA 01035-0779

Tel. (413) 253-8643
Email [email protected]

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

Tel. (303) 236-8171
Email [email protected]

1011 E. Tudor Road
(MS-201)
Anchorage, AK
99503

Tel. (907) 786-3693
Email [email protected]

2800 Cottage Way
Room W-2606
Sacramento, CA 95825

Tel. (916) 978-6183
[email protected]