3-200-91 Federal Fish and Wildlife Permit Application Form - Eagl

Form 3-200-91 (Rev. 01/2024) OMB Control No. 1018-0167

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

FEDERAL FISH AND WILDLIFE PERMIT APPLICATION FORM

Eagle Disturbance Take

(Bald and Golden Eagle Protection Act, 50 CFR 22.200 – 22.220 and 22.280)

U.S. Fish and Wildlife Service Division of Migratory Bird Management

TYPE OF REQUEST ^{BEFORE FILLING OUT THIS FORM, please access the}

New Application

Return Addresses (to obtain the email/postal mail addresses where this form can be returned), review the

Renewal ^{Frequently Asked Questions, and read the form}

^{Instructions.} Please retain the "NOTICES" page for your records.

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.

A. Complete if applying as an individual
1.a. Last name		1.b. First name	1.c. Middle name or initial	1.d. Suffix
2. Date of birth (mm/dd/yyyy)	3.a. Telephone number	3.b. Alternate telephone number	3.c E-mail address

B. 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			4.c. Principal officer Middle name/ initial		4.d. Suffix
5. Principal officer title				6. Primary contact name
7.a. Business telephone number	7.b. Alternate telephone number		7.c. Business fax number			7.d. Business e-mail address

C. 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.e. County/Province	1.f. Country
2.a. Mailing Address (include if different than physical address; include name of contact person if applicable)
2.b. City	2.c. State	2.d. Zip code/Postal code:	2.e. County/Province	2.f. Country

D. 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?
Yes		No		If yes, list the number of the most current permit you have held or that you are applying to renew/re-issue:
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

SECTION E. EAGLE DISTURBANCE TAKE

(Bald and Golden Eagle Protection Act, 50 CFR 22.200 – 22.220 and 22.280)

Note: A Federal eagle incidental take permit authorizes the disturbance of eagles where the take results from but is not the purpose of an otherwise lawful activity. Permits are available to individuals, agencies, Tribes, businesses, and other organizations. Please read “Frequently Asked Questions About a Federal Permit For Eagle Disturbance Take” and the pertinent regulations in 50 CFR Part 22, Subpart E before you sign and submit your application.

Please provide the information requested below. If you need to provide additional information that does not fit in the designated spaces below, add additional pages 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. You may include attachments that provide pertinent information; however, responses below should summarize information provided in these attachments and should reference section and/or page numbers where pertinent information can be found. We will not review large attachments in their entirety to find pertinent information unless properly referenced.

Your responses should be thorough and specific. Incomplete applications will be returned. Processing fees are nonrefundable regardless of whether a permit is issued, abandoned, or denied. The Service will not refund any application or renewal fee under any circumstances if we have processed the application (see 50 CFR 13.11(D1)). For specific permits, processing time depends on the complexity of the request and completeness of the application. Please allow a minimum of 60-90 days for initial application review. Complex applications, including those that require additional environmental compliance review, may take longer to process.

FOR RENEWAL APPLICATIONS: If you are applying for a renewal and wish to report changes to your activity or request changes to your permit conditions, please answer all questions in Section E below. For all other general permit renewals, please provide responses to questions 3, 5-11 and 13, and 20 below and respond “No Changes” to all other questions. For all other specific permit renewals, please provide responses to questions 3, 5-11, 15-16, and 19-20 below and respond “No Changes” to all other questions. All requested information must be provided, required reporting must be up to date, and processing fees paid, or the renewal will not be processed.

General and specific permit applications – Please complete questions 1-11 below. For specific permits, an Eagle Conservation Plan (ECP) or other attached documentation, may be cited if submitted with your application and properly referenced. The Service may provide guidance on developing complete and adequate application materials.

1. Permit Type. Please indicate which type of permit you are applying for:

• General ¨ Specific

2. Activity Description and Location. A detailed description of the activity that is likely to cause disturbance to eagles, including information on construction, demolition, vegetation removal, infrastructure, etc. that may disturb nesting eagle(s), as well timing and duration of these activities. Include a description of the location of the activity, including county/city/state information, latitude/longitude geographic coordinates (in decimal degrees), and datum of coordinates (if known). Provide any maps and photographs, if available.

3. Dates. The dates the activity that is likely to cause eagle disturbance will start and is projected to end. If the activity is already in progress, describe the stage of progress and why you are requesting a permit now.

4. Need. What interest will be protected by the activity causing take? Provide an explanation of why there is no practicable alternative to the activity that would protect the interest to be served while reducing likely impacts to eagles, including any avoidance and minimization measures that you implemented.

5. Description of Eagle Use and Activity. Describe the timing and intensity of eagle activity where disturbance is likely to occur.

1. Describe the eagle use in the project area, including the type, timing, and intensity of the eagle activity in the vicinity. For example, describe if eagle activity is centered around nest(s), roost(s), or other important eagle use area(s) (e.g., foraging areas, migration corridors, overwintering areas, etc.), how many eagles use these areas, and how frequently and when that use occurs.

2. Describe the location of eagle nests, roosts, and other important eagle use areas. Provide latitude/longitude geographic coordinates (in decimal degrees), datum of coordinates, maps, photographs, and other information. For eagle nests, describe current and historic (if known) nest status (e.g., in-use or alternate) and if any alternate nests are known to belong in the same territory as other nests described. If known, provide the distance(s) of nests and other important eagle use areas from the project activity/disturbance. If a nest where disturbance would occur is located within Indian Country as defined under 18 U.S.C. 1151, a general permit for nest disturbance is not available, unless requested by the Tribe itself.

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 not, provide the physical address.

8. Compliance with Laws and Regulations. 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?

• Yes ¨ Have Applied ¨ None Required

If “Yes,” attach a copy of the approval(s). If “Have applied”, submit a copy when issued.

9. Technical Assistance. 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 preparing this permit application, please provide your name, name of the consultant company, and contact information (phone/email).

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?

• Yes ¨ No

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). If you answered "Yes,” you will be required to apply for a specific permit.

General permit applications only:

12. Permit Tenure and Effective Date. For general permits for eagle disturbance take, the permit tenure is no longer than 1 year expiring on August 31. Please indicate whether you would like your permit effective date to start immediately upon issuance or if you would like your permit effective date to begin September 1. Permittees should consider the start date that best coincides with the disturbance activity. Selecting an immediate effective date may result in an overall shorter permit tenure, especially if the permit is issued close to August 31. If you choose to delay the effective date, take would only be authorized beginning on the permit effective date.

¨ Immediate effective date

¨ September 1

13. Certification. As part of your general permit application, you must certify that the below statements are true. Check each box to acknowledge.

• I meet all permit issuance criteria in § 13.21 and all eligibility requirements for general permits in § 22.280.

• My activity likely to cause disturbance to eagles is necessary to protect a legitimate interest in a particular locality.

• Eagle disturbance may result from but is not the purpose of my activity.

• Eagle disturbance resulting from my activity cannot be practicably avoided.

• My activity is not likely to result in the complete loss of an eagle territory.

• I agree to implement all permit conditions applicable to my activity, including those related to avoidance and minimization, monitoring, and reporting.

• My activity either does not affect a property that is listed, or is eligible for listing, in the National Register of Historic Places as maintained by the Secretary of the Interior; or I have obtained and am in compliance with, a written agreement with the relevant State Historic Preservation Officer (SHPO) or Tribal Historic Preservation Officer (THPO) that outlines all measures I will undertake to mitigate or prevent adverse effects to the historic property.

• I understand that, if implementing the conditions of a general permit may affect a species listed as threatened or endangered, a candidate species, or a species proposed to be listed as threatened or endangered, under the Endangered Species Act or designated or proposed critical habitat, eagle disturbance take authorization can only be provided under a specific permit.

Specific permit applications only: If you are requesting a specific permit, you must provide the information requested below. The Service may provide guidance on developing complete and adequate application materials.

14. Organization Type. Please indicate your status:

• Commercial ¨ Non-commercial

If “non-commercial,” you must provide documentation demonstrating you are a government agency or a current non-profit organization recognized by the Internal Revenue Service (IRS) as described in section 501(c)(3)).

15. Duration. What is the requested duration of the permit? Specific permits are issued for up to 5 years.

16. Impacts to Eagles. An eagle impacts assessment, including eagle activity and eagle use in the project area and a description of methods used to conduct this assessment.

17. Avoidance and Minimization. A description of implemented and proposed measures to avoid and minimize, to the maximum degree practicable, impacts to eagles from your activity, such as visual barriers to block the view of activities from the nest. Include the demonstrated tolerance of eagles to your activities and others in the vicinity.

18. Compensatory Mitigation. If your requested take is for golden eagle disturbance, a description of implemented and proposed measures to compensate for eagle take.

19. Monitoring. All other methods and information related to pre- or post-activity eagle monitoring. The Service will use the best available information to estimate eagle take that will result from the described activity.

For all applications:

20. I acknowledge that I have read the form Instructions and Frequently Asked Questions, and have accessed the page with the Return Addresses to obtain the address where I should return this form. I have also filled out all fields and questions in this application. Check this box to acknowledge: ¨

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 Disturbance Take (General)

Original submission - paper-based (Individuals): 5 hours (reporting) and 1 hour (recordkeeping)

Original submission - paper-based (Private sector and State/local/Tribal Govt): 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 Govt): 16 hours (reporting) and 2 hours (recordkeeping)

Eagle Disturbance Take (Specific)

Original submission - paper-based (Individuals, Private Sector, State/Local/Tribal Govt): 160 hours (reporting) and 40 hours (recordkeeping) Original submission - electronic (Individuals, Private Sector, State/Local/Tribal Govt): 140 hours (reporting) and 40 hours (recordkeeping)

Amendment - Eagle Disturbance Take (Specific)

Original submission - paper-based (Individuals, Private Sector, State/Local/Tribal Govt): 35 hours (reporting) and 5 hours (recordkeeping) Original submission - electronic (Individuals, Private Sector, State/Local/Tribal Govt): 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].