Form 3-200-41A Annual Report - Captive-Bred Wildlife Registration (CBW)

OMB Control No. 1018-0093
Expires XX/XX/XXXX

FWS Form 3-200-41a (Rev. 02/2023)
U.S. Department of the Interior

Captive-Bred Wildlife Registration (CBW) Annual Report
Due: March 31st of the following year
Email to: [email protected] referencing “CBW Annual Report YYYY for CBW # MA#####” in subject line.
Permittee Name: __________________________

Reporting Year ____________________ CBW Permit #: _____________________

Complete this form (all three tables) for ALL live, non-native, ESA-listed species, captive-bred in the U.S., covered under your current CBW registration for
the above reporting year (including individuals you have on loan with another facility, or on loan with you). Do not include non-native ESA-listed species that
were not covered on your CBW permit during this year.
Year-end Inventory
Scientific Name
(Genus, species, and if
applicable,
subspecies)

EXAMPLE:
Loxodonta Africana

Common Name

African Elephant

Quantity

Sex/Age Ratio
(male.female.unknown
sex, 10.5.2)

# Births
over the
reporting
year

17

10.5.2.

2

Approximate
Date of
Birth

1/15/2022
7/4/2022

# Deaths
over the
reporting
year

1

Use of this form is not mandatory. If using an alternate form, ensure it encompasses the same information. Additional information may be attached to the report.

Approx Death Date(s)
and Cause of Death(s)
(attach necropsy report,
as needed)

Aug 2019, old age

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OMB Control No. 1018-0093
Expires XX/XX/XXXX

FWS Form 3-200-41a (Rev. 02/2023)
U.S. Department of the Interior

Activities Conducted
CBW holder is required to disclose ALL interstate and intrastate purchases, sales, trades, and/or exports involving species listed under their CBW that
occurred during the reporting year.
Scientific
Name

Common
Name

Activity
(Interstate or
intrastate
purchases,
sales, and/or
exports)

EXAMPLE:
Loxodonta
africana

African
elephant

Interstate
purchase

Date of
Activity
(mm/dd/yy
yy)

04/12/2019

Quantity, Sex, Birth
Date (males.females.
unknown sex, 10.8.3)

1.0.0
6/30/2008

Name and Address of the
other party involved in the
transaction
(include country if an export)

CBW # of
Registrant
Involved in
Activity

Sunland Zoo and Park
300 Leopard Way, Miami, FL

Use of this form is not mandatory. If using an alternate form, ensure it encompasses the same information. Additional information may be attached to the report.

MA####

Identification
Information
(e.g., studbook #’s,
microchip #’s, band
#s, etc.)

Studbook #: 152

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OMB Control No. 1018-0093
Expires XX/XX/XXXX

FWS Form 3-200-41a (Rev. 02/2023)
U.S. Department of the Interior

Loans/Gifts/Donations Conducted
CBW holder is required it disclose ALL loans, donations, and gifts involving species listed under their CBW that occurred during the reporting year.
Scientific
Name

Common
Name

EXAMPLE:
Loxodonta
africana

African
elephant

Activity
(loans,
donations,
and gifts)

loan

Date of
Activity
(mm/dd/yyyy)

4/12/2019

Quantity, Sex, Birth
Date (males.females.
unknown sex, 10.8.3)

Name and Address of the other party
Involved in the transaction

1.0.0
6/30/2008

Sunland Zoo and Park

Information on transferred Animal(s)
(studbook #’s, microchip #’s, band #’s,
tattoo #’s, etc.)

300 Leopard Way, Miami, FL

Use of this form is not mandatory. If using an alternate form, ensure it encompasses the same information. Additional information may be attached to the report.

Studbook # 305
Tattoo yellow 6

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OMB Control No. 1018-0093
Expires ##/##/####

FWS Form 3-200-41a (Rev. 02/2023)
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 Marine Mammal Protection Act (16 U.S.C. 1361, et seq.), 50 CFR 18; 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. This helps 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
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) in order provide the U.S. Fish
and Wildlife Service the information necessary, under the applicable laws governing the requested activity, for which a
permit is requested. 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 applicable 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. 1018-0093.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages 1 hour (electronic and paper-based), including 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 (JAO/3W), Falls Church, VA 22041-3803, or via email at
[email protected]. Please do not send your completed form to this address.
Questions regarding permits from Management Authority should be sent to [email protected].

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