3-200-92 Federal Fish and Wildlife Permit Application Form - Eagl

Form 3-200-92 (Rev. 05/2022)
U.S. Department of the Interior

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

OMB Control No. 1018-0167
Expires ##/##/20##

Eagle Incidental Take – Power Lines
(Bald and Golden Eagle Protection Act, 50 CFR 22.260)
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

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

TYPE OF REQUEST
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:
Yes
No
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 3-200-92 (Rev. 05/2022)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/20##

SECTION E. EAGLE TAKE – ASSOCIATED WITH BUT NOT THE PURPOSE OF AN ACTIVITY
(INCIDENTAL TAKE)
(Bald and Golden Eagle Protection Act, 50 CFR 22.260)
Note: A Federal eagle incidental take permit authorizes the disturbance or other incidental take of eagles where the
take results from but is not the purpose of an otherwise lawful activity. Permits are available to individuals, agencies,
businesses, and other organizations. This permit does not authorize possession of any eagle, eagle parts, or eagle
nests. Please read “Frequently Asked Questions About a Federal Permit For Eagle Take Necessary To Protect An
Interest In A Particular Locality (Incidental Take)” and the pertinent regulations at 50 CFR 22.260 before you sign and
submit your application.
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. Please number pages accordingly using the
page number box provided at the bottom of the sheet, and the corresponding question number. We cannot accept
pages that are over 8.5” x 11” or non-paper media, such as DVDs.
You should be as thorough and specific as possible in your responses. Incomplete applications will be returned.
Processing fees are not returned for abandoned applications. Processing time depends on the complexity of the
request and completeness of the application, for short-term permit please allow 30-180 days and for long-term permit
please allow 1-2 years.

1. Duration. When do you want your permit to be effective (month/year)? How many years do you want your permit to be
valid? Specific permits may be issued for up to 30 years. General permits may be issued for 5 years.

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Form 3-200-92 (Rev. 05/2022)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/20##

2. Project Activity. Include any relevant information regarding your activity as it relates to eagles. You must include the
following:
a. Activity Description. A detailed description of your project. Including information on construction, demolition,
vegetation removal, infrastructure, etc. that may affect eagle(s).

b. Dates. The dates the activity will start and is projected to end. If the project has begun, describe the stage of
progress and why you are requesting a permit now.

c.

Need. An explanation of why the take of eagles is necessary, including what interests will be protected by the
project or activity.

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Form 3-200-92 (Rev. 05/2022)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/20##

d. Location. Describe activity location county/city information and, as appropriate, include: maps, digital
photographs, and latitude/longitude geographic coordinates of the proposed activity.

3. For Specific Permits Only. Eagle Activity. Include any known information eagle activity.
a. Eagle Activity Description. Describe the type of eagle activity, for example nest(s), roost(s), important use
area(s) (foraging, migration, overwintering), etc.

b. Location. Describe the location of eagle nests, roosts, and/or use areas including latitude/longitude geographic
coordinates and, as appropriate, maps, digital photographs, and other information. The Service cannot issue a permit to
disturb a nest if the location of the nest is not provided. (The latitude and longitude coordinates of an eagle nest can be
determined using a hand-held GPS device, or a GPS mapping program on a cell phone. If neither of these are available,
you can use the Google Earth program, available free online from Google for personal use, or at most public institutions
that provide computer access (e.g., public libraries). Google Earth provides detailed satellite images worldwide, and the
scale of the imagery is such that individual trees, cliffs, and other possible nest structures are easily identifiable. In
Google Earth, the geographic coordinates of the computer cursor are provided in the lower right hand corner of the
computer screen, so by placing the cursor on the nest tree you can obtain its geographic coordinates. Google Earth has
a number of options for the coordinates it provides, and the coordinates it displays can be selected by the user. In
Google Earth Pro, the version of Google Earth that is in widest use today, the coordinates that are displayed can be
selected from the "Tools" dropdown menu, under "Options." Within the Options menu, select "3D View". The Service
prefers latitude longitude coordinates in decimal degrees, and this is one of the options that can be selected within the
"Show Lat/Long" box that appears under the 3D View menu. To test whether you are obtaining the correct coordinates,
move your cursor to the Washington Monument -- the coordinates should read latitude 33.889, longitude -77.035.)

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Form 3-200-92 (Rev. 05/2022)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/20##

c. History. If known, include the history of nest occupation, roost use, or important area use.

d. If known, provide the specific distance and locations of nests and other eagle-use areas from the project footprint.

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Form 3-200-92 (Rev. 05/2022)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/20##

5. For Specific Permits Only. Provide a detailed description of all avoidance, minimization, mitigation, and
monitoring measures that you have incorporated into your planning for the activity that you will implement to reduce
the likelihood for take of eagles. For long-term projects, this can be included in your Eagle Conservation Plan.

6. Subpermittees. Anyone conducting permitted activities or acting as your agent must be identified by you, in writing,
as a subpermittee under your permit. Your subpermittees must have either a copy of your permit that identifies them as
a subpermittee, or a copy of your permit and a letter from the Permittee (Principal Officer) listing activities (including
location and duration) they are authorized to conduct. The permittee is responsible for ensuring subpermittees are
trained and adhere to the conditions of your permit. Subpermittees must be at least 18 years of age. A permittee or
subpermittee must be present when conducting activities.

7. Records. You must retain records legibly written or reproducible in English relating to the activities conducted under
your permit for at least 5 years from the date of expiration of the 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
8. You are responsible for ensuring that the permitted activity is in compliance with all Federal, tribal, State, and local laws
and regulations applicable to eagles. Have you obtained all required State or Tribal permits or approvals to
conduct this activity? Indicate “Yes,” Have applied,” or None required.” If “Yes,” attach a copy of the approval(s). If
“Have applied,” submit a copy when issued.
Yes
Have applied
None required
9. The name and contact information for any U.S. Fish and Wildlife Service employee(s) who has provided technical
assistance or worked with you on this project. If you have received technical assistance for your project from your
State wildlife agency, please provide the name and contact information for the individual(s).

10. Consultant: If you are a consultant submitting this permit application, please provide your name and contact information
(phone/email).

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Form 3-200-92 (Rev. 05/2022)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/20##

11. Disqualification factor. A conviction, or entry of a plea of guilty or nolo contendere, for a felony violation of the Lacey
Act, the Migratory Bird Treaty Act, or the Bald and Golden Eagle Protection Act disqualifies any such person from
receiving or exercising the privileges of a permit, unless such disqualification has been expressly waived by the Service
Director in response to a written petition. (50 CFR 13.21(c)) Have you or any of the owners of the business, if applying
as a business, been convicted, or entered a plea of guilty or nolo contendere, forfeited collateral, or are currently under
charges for any violations of the laws mentioned above? Indicate “Yes” or “No.”(you must provide an answer). If you
answered “Yes” provide: a) the individual’s name, b) date of charge, c) charge(s), d) location of incident, e) court, and f)
action taken for each violation. (list all – use additional pages as necessary)

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Form 3-200-92 (Rev. 05/2022)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/20##

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 et seq.), 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 public reporting burden on the applicant for information collection varies depending on the activity for which a permit is requested. The
relevant burden for this information collection, based on the activity performed, including time for reviewing instructions, gathering and
maintaining data and completing and reviewing the form is as follows:
Eagle Incidental Take - Power Lines (General)
Original submission - paper-based (Individuals): 5 hours (reporting) and 1 hour (recordkeeping)
Original submission - paper-based (Private sector and State/Local/Tribal governments): 18 hours (reporting) and 2 hours (recordkeeping)
Original submission - electronic (Individuals): 4 hours (reporting) and 1 hour (recordkeeping)
Original submission - electronic (Private sector and State/Local/Tribal governments): 16 hours (reporting) and 2 hours (recordkeeping)
Amendment - Eagle Incidental Take - Power Lines (General)
Original submission - paper-based: 35 hours (reporting) and 5 hours (recordkeeping)
Original submission - electronic: 33 hours (reporting) and 5 hours (recordkeeping)
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 (JAO/3W), 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].