Form 3-2274 U.S. Title 50 Certification Form

F WS Form 3-2274 (Rev. 05/2023) OMB Control No. 1018-0078

U.S. Department of the Interior Expires ##/##/20##

TITLE 50 CERTIFICATION FORM

(To be filled out by the Aquatic Animal Health Inspector)

Please provide a copy to the importer and return an original signed copy to:

U.S. Fish and Wildlife Service

Branch of Hatchery Operations and Applied Science

Attn: Title 50 Certification Form

5275 Leesburg Pike, MS: FAC

Falls Church, VA 22041

USA

I,       , designated by the Director of the U.S. Fish and Wildlife Service on       ,

^{Certifying Official’s Name Date of Most Recent Certification}

as required by Title 50, CFR 16.13, do hereby certify the following:

1. The fish lot(s) of origin for this shipment of up to a maximum of      

     

^{List Numbers, Life Stage(Eggs or Fish), and Species for This Shipment That Are Covered by This Inspection}

were most recently sampled at      

^{Site of Sample Collection (Name and Address)}

on       .

^{Date of Sample Collection}

Viral assays were performed on these samples at      

^{Name and Address of Laboratory Conducting the Assays}

and completed on      .

^{Date the Assays Were Completed}

Sampling and viral assays were conducted using methodology described in Title 50 CFR 16.13.

2. Oncorhynchus masou virus (OMV), and the viruses causing viral hemorrhagic septicemia(VHS), infectious hematopoietic necrosis (IHN), and infectious pancreatic necrosis (IPN) have not been detected in viral assays of fish lot(s) of origin of eggs or fish.

3. This shipment is scheduled to depart      

^{Site From Which the Fish Will Be Shipped (Name and Address)}

between       and      

^{Dates Indicating Time Frame The Shipments Will Take Place}

via      

^{Means By Which the Shipment Will Be Made (Include Name of Transport Company and Bill of Lading Numbers, Flight Numbers, Etc. if Known}

crossing into the United States at       with the destination of

^{Name of Anticipated Border Crossing}

     

^{Name and Address of Recipient}

4) Other information of relevance:

     

     

     

Signature: Date:      

Name:      

Organization:      

Street Address:      

City:       State/Province:       Zip Code:      

Country:      

Phone:       Fax:      

Email Address:      

NOTICES

Privacy Act Statement

Authority: The information requested is authorized by the Lacey Act (18 U.S.C. 42) and Title 50, Part 16 of the Code of Federal Regulations.

Purpose: The information requested is used the FWS Certifying Official to affirm the health status of certain imports.

Routine Uses: The collected information may be disclosed in accordance with the Privacy Act of 1974 and the routine uses listed System of Records Notice (SORN) INTERIOR/FWS-21, Permits System (September 4, 2003) 68 FR 52610; modification published (March 16, 2023) 88 FR 16277 and available at www.doi.gov/privacy/fws-notices.

Disclosure: Furnishing this information is voluntary; however, failure to provide all requested information may prevent you from being able to import into the U.S.

PAPERWORK REDUCTION ACT STATEMENT

The U.S. Fish and Wildlife Service collects this information subject to the Paperwork Reduction Act (44 U.S.C. 3501 et seq.) in order to consider your request for certification as a Title 50 inspector under Title 50, Part 16, of the Code of Federal Regulations. Information requested in this form is required to obtain or retain a benefit. Failure to provide all requested information may be sufficient cause for the 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. 1018-0078.

ESTIMATED BURDEN STATEMENT

Public reporting for this collection of information is estimated to be 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Service Information Collection Clearance Officer, Division of Policy, Performance, and Management Programs, Fish and Wildlife Service, MS: PRB (JAO/3W), 5275 Leesburg Pike, 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 STATEMENT

Information provided to the Service is generally subject to release to the public under the Freedom of Information Act (FOIA). Certain information, however, may be subject to withholding if the Service determines that the information is a trade secret and/or commercial or financial information that is privileged or confidential. To the extent you are submitting business information that falls into one of these categories, you must clearly mark this information as "Business Confidential" in order for the Service to assess the applicability of FOIA Exemption 4. Any information provided by you that is not marked as “Business Confidential” will be considered releasable to the public under the FOIA [43 CFR 2.26 – 2.33].

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