Form 3-202-16 Annual Report - Eagle Nest Take (22.27)

FWS Form 3-202-16 (Rev. 02/2020)
U.S. Department of the Interior

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE

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

EAGLE NEST TAKE (50 CFR 22.27) - 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: ___________________________________________________

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: Complete all sections in the space provided or numbered accordingly to the questions below on a separate sheet of paper 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. Filing an annual report is a condition 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)
1.  Bald Eagle Nest Take

 Golden Eagle Nest Take

2. Did (does) the permit authorize take of a specific nest or nests?

 Yes.

 No, the permit authorizes programmatic nest take.

3. Provide the following information for each authorized nest take. If more than one nest was taken, please complete a supplemental page for each nest.
A. Date the authorized nest take occurred: ____ /____/_______
B. Location of the nest that was taken: _________________________________________________________________________________________
C. If the nest was active, disposition of chicks and eggs (e.g., name and contact information of permitted rehabilitator, State agency, or USFWS):
_______________________________________________________________________________________________________________________
D. Disposition of the nest. Check all that apply: Removed

 Destroyed

 Relocated

 Donated to a permitted recipient

 Yes
 No
a. Have eagles rebuilt and if so, are they breeding and fledging young?
b. If nest was relocated or a substitute nest provided, are adult eagles tending the new nest? Yes
 Do not know Not applicable.

No

 Substitute nest provided

 No, but nest removal was conducted outside eagle
breeding season

c. If nest was relocated or a substitute nest provided, provide location:_______________________________________________________________
d. If nest was relocated, please attach a description of methods and techniques employed to move it.
4. Describe the mitigation measures you are implementing to offset the nest take and/or minimize the need for future nest take.
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. 1018-0167
Expires ##/##/####

FWS Form 3-202-16 (Rev. 02/2020)
U.S. Department of the Interior

EAGLE NEST TAKE REPORT

SUPPLEMENTAL SHEET
REPORT DATE ____________

PERMITTEE:_____________________________________

PERMIT NUMBER:__________________

SUPPLEMENTAL PAGE #:____

3. Provide the following information for each authorized nest take.
A. Date the authorized nest take occurred: ____ /____/_______
B. Location of the nest that was taken: ________________________________________________________________________________________
C. Disposition of the nest: Destroyed Relocated within territory Relocated outside territory Donated to a permitted recipient
Destroyed, substitute nest provided in territory Destroyed, substitute nest provided outside territory
D. If nest was relocated or a substitute nest provided, are adult eagles tending the new nest? Yes
 Do not know.

No

No, but nest removal occurred outside the eagles
breeding season

E. If nest was active, disposition of chicks and eggs (e.g., name and contact information of permitted rehabilitator, State agency, or USFWS):
______________________________________________________________________________________________________________________
4. Describe the mitigation measures you have conducted to offset the nest take. If your permit does not require mitigation, you may leave this blank.

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

FWS Form 3-202-16 (Rev. 02/2020)
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 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
The relevant burden for an Eagle Nest Take permit annual report is 16 hours (including monitoring and recordkeeping). This burden estimate includes 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 non-confidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].