Form 3-200-16 Federal Fish and Wildlife Permit Application Form - Take

Form 3-200-16 (Rev. 02/2020)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

OMB Control No. 1018-0167
Expires ##/##/####

Take of Depredating Eagles & Eagles that Pose a Risk to Human Health or Safety
(Bald and Golden Eagle Protection Act, 50 CFR 22.23)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management
TYPE OF REQUEST

BEFORE FILLING OUT THIS FORM, please access the
Return Addresses (to obtain the email/postal mail
addresses where this form can be returned), and read
the Frequently Asked Questions and Instructions. Please
retain the "NOTICES" page for your records.

New Application
Renewal
Amendment

If requesting a renewal or amendment, provide permit #
Complete Sections A or B, and C, D, and E of this application. U.S. address may be required in Section C, see instructions for details. See
instruction page(s) for information on how to make your application complete and help avoid unnecessary delays.

Complete if applying as an individual

A.

1.a. Last name

1.b. First name

2. Date of birth (mm/dd/yyyy)

B.

3.b. Alternate telephone number

3.a. Telephone number

1.c. Middle name or initial

1.d. Suffix

3.d. E-mail address

Complete if applying on behalf of a business, corporation, public agency, Tribe, or institution

1.a. Name of business, agency, Tribe, or institution

1.b. Doing business as (dba)

2. Tax identification no.

3. Description of business, agency, or institution

4.a. Principal officer Last name

4.b. Principal officer First name

5. Principal officer title

4.c. Principal officer Middle name/ initial 4.d. Suffix

6. Primary contact name

7.a. Business telephone number 7.b. Alternate telephone number

C.

7.c. Business fax number

7.d. Business e-mail address

All applicants complete address information

1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes)
1.b. City

1.c. State

1.d. Zip code/Postal code:

1.f. Country

1.e. County/Province

2.a. Mailing Address (include if different than physical address; include name of contact person if applicable)
2.b. City

D.

2.c. State

2.d. Zip code/Postal code:

2.e. County/Province

2.f. Country

All applicants MUST complete

1. A nonrefundable processing fee is required to process this permit, please attach check or money order payable to the U.S. FISH AND WILDLIFE
SERVICE. Federal, Tribal, State, and local government agencies, and those acting on behalf of such agencies, are exempt from the processing fee –
Please see link for processing fee cost and fee exempt status as outlined in 50 CFR 13.11(d). Click here for Processing Fees
2. Do you currently have or have you ever had any Federal Fish and Wildlife permits?
If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue:
No

Yes

3. Certification: I hereby certify that I have read and am familiar with the regulations contained in Title 50, Part 13 of the Code of Federal Regulations and
the other applicable parts in subchapter B of Chapter I of Title 50, and I certify that the information submitted in this application for a permit 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 of applicant/Principal Officer (No stamped signatures. Electronic signatures accepted.)

Date of signature (mm/dd/yyyy)

Please continue to next page

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Form 3-200-16 (Rev. 02/2020)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

OMB Control No. 1018-0167
Expires ##/##/####

Take of Depredating Eagles & Eagles that Pose a Risk to Human or Eagle Health or Safety
(Bald and Golden Eagle Protection Act, 50 CFR 22.23)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

NOTE: A Federal Eagle Depredation Permit is required take Bald Eagles or Golden Eagles that have become injurious to wildlife,
agriculture or other personal property, or for human or eagle health or safety. A depredation permit is intended to provide short-term
relief from depredation damage until long-term measures can be implemented to reduce or eliminate the depredation problem through
nonlethal control techniques. Long-term measures might include constructing enclosures or changing their design, alteration of habitat
or features to remove attractants, or modification of land-use practices that attract eagles. You should review Title 50 Parts 10, 13, and
22.23 of the Code of Federal Regulations (CFR). You are responsible for reviewing and understanding these regulations before you
request and accept a permit. These regulations can be found on our website at https://www.fws.gov/birds/policies-and-regulations/
permits/permit-policies-and-regulations.php. You must be at least 18 years old to apply for this permit.
Please provide the information requested below. If additional information needs to be provided that does not fit in the designated
spaces, add additional sheets to your application submission. You may use as many additional sheets as needed. Please number
pages accordingly using the page number box provided at the bottom of the sheet, and the corresponding question number.
We may request additional information as appropriate to the activities you are requesting (50 CFR 13.21(d)). You should be as thorough
and specific as possible in your responses. Incomplete applications will be returned. If you are requesting renewal, you still need to
complete the entire application and provide all the requested information.
If you are requesting renewal, all required reporting must be up to date or the renewal will not be processed. The report form can be
found at https://www.fws.gov/forms/3-202-11.pdf. If you are requesting renewal, you only need to provide information that has
changed since your prior application.
As the permittee, you are legally responsible for ensuring that your subpermittees, staff, and volunteers adhere to the terms of your
permit.
Federal Eagle Depredation permits cannot not be issued for longer than 90 days, except permits to authorize disturbance associated
with hazing eagles from the vicinity of an airport, which may be valid for up to 5 years.

SECTION E.
Questions

1) Attachments - In addition to this form, you should also attach the following to complete your application:
a) Your application for a depredation permit must include a recommendation from the U.S. Department of Agriculture, Animal
and Plant Health Inspection Service, Wildlife Services, for addressing your depredation problem. Contact Wildlife Services at
(866) 487-3297. If Wildlife Services recommends that a permit be issued, they will complete a Wildlife Services Permit
Review Form (Form 37). Attach a copy of the completed Form 37. Your application will be considered incomplete if you fail
to include a current Form 37 with your application. The information contained on the Form 37 is similar to the information
that is requested below. You must also complete each section below that is applicable to your situation;
b) Optional: copies of any receipts, invoices, contracts, necropsy reports, or other available records documenting any deterrent
measures can be helpful in processing your application;
c) Any other supporting documentation (example photographs of damages);
d) The report form for this permit application can be found at: https://www.fws.gov/forms/3-202-16.pdf

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Form 3-200-16 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/####

2) Any permit issued as a result of this application is not valid unless you also have any required State or tribal permits or
approvals associated with the activity. Have you obtained all required State or tribal permits or approvals to conduct this
activity?
Yes, Have Attached
None Required
Have Applied, Will Provide Upon Request
3) List the species of eagles, and estimate the number of individuals of each species, that are causing depredation problems.
Bald Eagle, number _______
Golden Eagle, number _______
(a) What are the specific details for the depredation or injuries you are experiencing? Include details such as types of
crops/livestock destroyed or property damaged. Include number livestock injured or killed, if applicable. Include risks to
human health and safety hazards. What is the extent of the damage and estimate the economic loss suffered as a
result, such as percentage of acres of crop and dollar loss, cost to replace damaged property, or cost of injuries?
Attach copies of any receipts, invoices, contracts, or other available documentation to support your estimates. If there is
risk to human health or safety, or to eagle health and safety, provide details.

(b) How long has this depredation been occurring (provide number of days, months, or years)?

(c) When during the year does this depredation or human safety hazard occur?

(d) What is the size of the area affected (e.g. 1-acre pond, 50-acre vineyard, 500-acre airfield)?

(e) How long are you requesting the permit for and how often will you be conducting depredation activities?

4) What is location of the property or properties where the take activity would be conducted? Include state, county, physical
address, and latitude/longitude in decimal degrees (e.g. 36.87998 N/ 88.3435 W). For assistance determining the latitude/
longitude for a specific location in decimal degrees, please visit https://earthexplorer.usgs.gov/.

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Form 3-200-16 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/####

5) Describe the following with your justifications:
(a) your requested method(s) of take, including type(s) of trap(s);

(b) your proposed trapping methods;

(c) who will be conducting any trapping and describe their previous experience;

(d) if you are requesting authorization for trap and relocation, identify the areas to be used for relocation. (Always ask
for landowner and state permission to release relocated eagles.)

6) Describe the deterrents that you have used previously to address this depredation situation, specifically addressing the
following nonlethal measures. Photographs or other documentation of the situation can assist us in reviewing your
application.
a) What habitat management measures (e.g., vegetative barriers, longer grass management, fencing and netting)
have you used to discourage depredation by eagles?

b) What cultural practices (e.g., crop selection, crop placement, animal and pet management, feeding schedules,
and no-bird-feeding policies) have you established to discourage depredation in the areas you have identified?

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Form 3-200-16 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/####

7) A depredation permit is not considered a long-term solution for most situations. What is your long-term plan to address
your depredation situation to eliminate or significantly reduce the continued need for the intentional take or disturbance
(hazing) of eagles? Non-lethal deterrents must be used daily or frequently to the extent practicable.

8) Indicate whether or not you are applying on behalf of an airport for a permit to control birds in flight zones. If you are
operating under an FAA-approved WHMP, please provide provide an electronic copy of the most recent plan along with your
application.
I am not applying on behalf of an airport
I am applying on behalf of an airport
9) You must retain records legibly written or reproducible in English relating to the activities conducted under your permit for at
least 5 years after the date of expiration of your permit. Is the physical address you provided in Section C on page 1 of this
application the address where your records will be kept?
Yes
No
If “no,”provide the
physical address:

10) Anyone who will be assisting you with the permitted activities or acting as your agent must either have their own Federal
migratory bird permit for the activity or be identified by you, in writing, as a subpermittee under your permit. They may also
require a State permit. Subpermittees must be at least 18 years old. As the primary permittee, you will be responsible for
ensuring that your subpermittees are properly trained and adhere to the terms of your permit. Provide the name of any
subpermittees who will be conducting activities under your permit. Include any commercial company that may be contracted to
conduct the work.

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Form 3-200-16 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/####

11) Disqualification factor. Have you, the permittee, or your client (if a broker on behalf of your client):
12) Been assessed a civil penalty or convicted of any criminal provision of any statue or regulation relating to the activity for which the
application is filed (50 CFR 13.21(b) (1)?
13) Been convicted, or entered a plea of guilty or no lo contendere, for a felony violation of the Lacey Act, the Migratory Bird Treaty Act,
or the Bald and Golden Eagle Protection Act. (50 CFR 13.21 (c)(1))?
14) Had a permit revoked within the last five years for willfully violating any Federal or State statute or regulation, or any Indian tribal law
or regulation, or any law or regulation of any foreign country, which involves a violation of the conditions of the permit or of the laws
or regulations governing the permitted activity (50 CFR 13.28 (a)(1)) or failing to correct deficiencies that were the cause of a
permit suspension within 60 days (50 CFR 13.28 (a)(2))?
Answer "yes" if ANY of the events listed immediately above (11-14) have occurred. Answer "no" if none of the events
listed immediately above have occurred.

Yes
NO
If you answered “Yes”, provide: a) the individual’s name; b) date of conviction, civil penalty assessment or revocation;
c) charge(s), or reason(s) for revocation; d) location of the incident; e) court (if applicable, ticket, federal/state/tribal court etc.); and f) legal
action taken for each violation (i.e. fine, incarceration, probation, or other). Please be aware that a “Yes” response does not automatically
disqualify you from getting a permit.

15) Are you eligible for Fee Exempt Status? Fee exempt status applies to government agencies (Federal, State, Tribal, and
municipal governments). Applicants acting on behalf of such agencies must submit either a letter on agency letterhead and
signed by the head of the unit of government for which the applicant is acting on behalf, confirming that the applicant will be
carrying out the permitted activity for the agency, or the agencies tax exempt form.
Yes - Government Agency
Yes - Acting on behalf of Government Agency
Documentation Included
No - not eligible for Fee Exempt Status
16) I acknowledge that I have read the form Instructions and FAQ, and have accessed the page with the Return Addresses to obtain
the address where I should return this form, and have filled out all fields and questions. I have also obtained a completed Form 37
from Wildlife Services and will include it with my application. Check this box to acknowledge:
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Form 3-200-16 (Rev. 02/2020)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/####

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 that affect protected
species. The information the individual provides helps the FWS monitor and report on protected species and assess 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. 1018-0167.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages:
Original submission - paper-based: 3 hours (reporting) and 30 minutes (recordkeeping)
Original submission - electronic: 2 hours 30 minutes (reporting) and 30 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].

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