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

FWS Form 3-200-91 (Rev. 7/2024)
DEPARTMENT OF THE INTERIOR

OMB Control. No. 1018-0167
Expiration Date: 07/31/2026

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 Bird Conservation, Permits, and Regulations
TYPE OF REQUEST

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

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.
A.
Complete if applying as an individual
1.a. Last name

2. Date of birth (mm/dd/yyyy)

B.

3.a. Telephone number

1.b. First name

1.c. Middle name or initial

3.b. Alternate telephone number

3.c. E-mail address

1.d. Suffix

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.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

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?
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
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FWS Form 3-200-91 (Rev. 7/2024)
U.S. Fish and Wildlife Service

OMB Control. No. 1018-1067
Expiration Date: 07/31/2026

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 permit renewal and wish to report changes to your activity,
please answer all questions applicable to your permit type in Section E below. If you are applying for renewal with no
changes to your activity, respond “No Changes” to all questions. For all specific permits, please ensure that you are
providing all updated information on eagle use and nest locations for your activity. All requested information must be
provided, required reporting must be up to date, and processing fees paid, or the renewal will not be processed.
All 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.

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FWS Form 3-200-91 (Rev. 7/2024)
U.S. Fish and Wildlife Service

OMB Control. No. 1018-1067
Expiration Date: 07/31/2026

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.

a. 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.

b. 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.

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FWS Form 3-200-91 (Rev. 7/2024)
U.S. Fish and Wildlife Service

OMB Control. No. 1018-1067
Expiration Date: 07/31/2026

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 submitting 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.

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FWS Form 3-200-91 (Rev. 7/2024)
U.S. Fish and Wildlife Service

OMB Control. No. 1018-1067
Expiration Date: 07/31/2026

General Permit Applications Only – Please complete questions 12-13 below.
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.
September 1

Immediate effective date

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 – Please complete questions 14-19 below.
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.

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FWS Form 3-200-91 (Rev. 7/2024)
U.S. Fish and Wildlife Service

OMB Control. No. 1018-1067
Expiration Date: 07/31/2026

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:

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FWS Form 3-200-91 (Rev. 7/2024)
U.S. Fish and Wildlife Service

OMB Control. No. 1018-1067
Expiration Date: 07/31/2026

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].

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