Form 3-202-5 Migratory Bird Special Purpose - Possession of Live and/

FWS Form 3-202-5 (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0022
Expires ##/##/####

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
MIGRATORY BIRD SPECIAL PURPOSE - POSSESSION OF LIVE AND/OR DEAD AND SALVAGE OF
MIGRATORY BIRDS FOR EDUCATIONAL PURPOSES - ANNUAL REPORT
Return to: U.S. Fish and Wildlife Service (USFWS)
BEFORE FILLING OUT THIS FORM, please access the Return Addresses (to obtain the email/
postal mail addresses where this form can be returned).

PERMITTEE: ____________________________________________________________
ADDRESS: _______________________________________________________________
_______________________________________________________________
Zip Code
City
State
 Check here if reporting a change of name, address, or contact information

PERMIT NUMBER:_________________________
REPORT FOR CALENDAR YEAR: _______________
REPORT DUE DATE: ___________________________

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

PHONE: ___________________________ Email: _____________________________________

INSTRUCTIONS: This form is for reporting activities conducted under Special Purpose Possession Permits for both Live and Dead birds. Type or print the information requested below for all birds or
parts acquired, salvaged, or held 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 the 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. MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT
BELOW BEFORE YOU SUBMIT YOUR REPORT. (Ref. 50 CFR parts 13 & 21). ALL THE INFORMATION REQUESTED IN THE TABLE BELOW IS REQUIRED TO BE PROVIDED. There are no
optional fields.
Species Inventory
(Common Name)

Live (L) or
Dead (D describe part)

Date
acquired/
salvaged

Date
Disposed
of

From
whom
acquired
or
to
whom
transferred (Name/Organization, City, State,
Permit #), or location (landowner, city, state)
where salvaged

Total Number of
Programs the bird was
used for (including onand off-site)

If on Static Display,
number of days the
facility was open to the
public

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 stamped signatures. Electronic signatures accepted.)

________________________________________________________
Date of signature (mm/dd/yyyy)

OMB Control No. 1018-0022
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FWS Form 3-202-5 (Rev. 01/2020)
U.S. Department of the Interior
SUPPLEMENTAL SHEET - SPECIAL PURPOSE POSSESSION - EDUCATION - ANNUAL REPORT
PERMITTEE:
Species
Inventory
(Common Name)

______________________
Live (L) or
Dead (D describe part)

_______
Date
Acquired

PERMIT NUMBER:
Date
Disposed
of

_____

REPORT YEAR:

From whom acquired or to whom transferred
(Name/Organization, City, State, Permit #)

SUPPLEMENTAL PAGE NO:
Total Number of
Programs the bird was
used for (including onand off-site)

If on Static Display,
number of days the
facility was open to the
public

OMB Control No. 1018-0022
Expires ##/##/####

FWS Form 3-202-5 (Rev. 01/2020)
U.S. Department of the Interior

NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the following: the Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22; the Endangered Species Act (16
U.S.C. 1531-1544), 50 CFR 17; the Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21; the Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15; the Lacey Act:
Injurious Wildlife (18 U.S.C. 42), 50 CFR 16; Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), 50 CFR 23; General Provisions, 50 CFR
10; General Permit Procedures, 50 CFR 13; and Wildlife Provisions (Import/export/transport), 50 CFR 14.
Purpose: The collection of contact information is to verify the individual has an eligible permit to conduct activities which affect protected species. The information the individual
provides helps the FWS monitor and report on protected species and assesses the impact of permitted activities on the conservation and management of species and their habitats.
Routine Uses: The collected information may be used to verify an applicant’s eligibility for a permit to conduct activities with protected wildlife; to provide the public and the permittees
with permit related information; to monitor activities under a permit; to analyze data and produce reports to monitor the use of protected wildlife; to assess the impact of permitted
activities on the conservation and management of protected species and their habitats; and to evaluate the effectiveness of the permit programs. More information about routine uses
can be found in the System of Records Notice, Permits System, FWS-21.
Disclosure: The information requested in this form is voluntary. However, submission of requested information is required to process applications for permits authorized under the
listed authorities. Failure to provide the requested information may be sufficient cause for the U.S. Fish & Wildlife Service to deny the request.
PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects information necessary to monitor take and disposition of migratory birds,
under the applicable laws governing the requested activity, for which a permit is requested, and to respond to requests made under the Freedom of Information Act and the Privacy Act
of 1974. Information requested in this form is purely voluntary. However, submission of requested information is required in order to process applications for permits authorized under
the above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the request. 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 collection of information and assigned Control No. 1018-0022.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages:
Original submission - paper-based: 1 hour 15 minutes (reporting) and 15 minutes (recordkeeping)
Original submission - electronic: 1 hour (reporting) and 15 minutes (recordkeeping)
These estimates include time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any
other aspect of the form to the Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS: PRB/PERMA (JAO), Falls
Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed form to this address.
FREEDOM OF INFORMATION ACT
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 nonconfidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

OMB Control No. 1018-0022

Expires 04/30/2021