WS Form 68 Wildlife Services Abatement Program Assignment of U.S. G

U.S. DEPARTMENT OF AGRICLULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
ANIMAL DAMAGE CONTROL

OMB Control No.
0579-XXXX

WS ABATEMENT PROGRAM ASSIGNMENT OF U. S. GOVERNMENT PROPERTY
1. THE FACILITIES/PROPERTIES/NAME OF PERSON/ENTITY INDICATED IN THIS AGREEMENT: (mark one of the following boxes):
represent(s) a government agency or entity
are/is registered in the State as a business, Corporation, LLC, LLLP, or LP
represent(s) a sole-proprietorship or dba of a sole proprietorship
is a private citizen with no business status

2a. COOPERATOR’S NAME

2b. ADDRESS

2c. PHONE
2d. SSN / TAX I.D.
3.

DEER

BEAR

MOOSE

COYOTE

OTHER

4. ISSUE DATE
5. TABLE OF ASSIGNMENTS:

5A. DEER OR MOOSE
FENCING

Quan.

Yearly
Rental

Electric HV Tape (660’ roll)
Small Rolls = $5.00/each/year
3/8” X 4’ Fiberrod Posts
@ $.30 each/year
3/8” POST CLIPS (Free)

5B. COYOTE OR BEAR
FENCING

Quan.

Yearly
Rental

Flex-Net (35” X 82’)
@ $12.00/year
Flex-Net (42” X 164’)
@ $24.00 each/year
AN 90 FENCER (9 V BATT.)
@ $25.00 each/year
ELECTRIC FENCER: V 1000 /
D-1B (12V BATT.) @ $35.00
each/year
ELECTRIC FENCER: D-2B
(12V BATT.) @ $40.00 each/year

1/2” BY 5’ FIBERROD POSTS
@$.75 each/year
ELECTRIC FENCER: P 500 / D1 (110V) @ $25.00 each/year
ELECTRIC FENCER: P 1000 /
D-2 (110V) @ $35.00 each/year

5C. OTHER EQUIPMENT
(Describe below)

LIGHTNING ARRESTOR
8-LITE VOLTMETER (Free)
PIN LOCK INSULATORS
@ $ 1.50 /bag/year
P-SPRINGS @ $ .30 each /year
5D. TOTAL RENTAL PER YEAR – ALL ASSIGNMENTS

→
5D X YEARS

5E. TOTAL TO OWN AFTER

YEARS PAID RENT

→

6. The equipment listed above is temporarily assigned to the cooperator whose signature is affixed below, for the purpose of controlling wildlife
damage to agriculture crops/livestock. FIRST YEAR’S RENT MUST BE PAID AT THE TIME OF ISSUE. These items will become the
property of the cooperator upon final payment of five years rent. The cooperator has received instructions on the safe use of the assigned
equipment, and accepts full responsibility for the safe operation and maintenance of the equipment. Additionally, the cooperator agrees to
release the U.S. Department of Agriculture, Animal & Plant Health Inspection Service, Wildlife Services and their designated agents from any
liability for personal injury and property damage arising from the operation and use of the assigned equipment. Should the equipment be lost, stolen
or damaged (except for normal wear and tear), the cooperator will be responsible for the balance due.

7. COOPERATORS SIGNATURE
_______________________________________

8. WS REPRESENTATIVE SIGNATURE
__________________________________
9.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0579-XXXX. The time required to complete this
information collection is estimated to average .0195 minutes/hours 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.

WS FORM 68

Instructions for Using FORM 68 WS Abatement Program Assignment of U. S. Government Property
WS Form 68 is used to record supply and/or equipment transfers between WS and a Cooperator participating in a damage
abatement program. This document is filled out by a program manager, program assistant, program budget assistant, or a
field employee. Information contained in this form is compiled from information volunteered by the Cooperator, and
information provided by a WS Representative. This form may be completed using pen and ink or typewriter for hard copy
documents, or the information may be entered by computer on electronic versions of the form. This form may not be altered
as to the amount and type of information collected thereon without Office of Management and Budget approval. Any
alterations related to language or structure must be approved by OSS. Contact the Forms Officer, OSS, 301/734-7921 with
questions.
1. Mark the appropriate box to indicate the status of the Cooperator. The Cooperator should provide this information.
Consult “Definitions” in this instruction sheet for guidance on identifying status types.
2. Cooperator Information: In boxes provided: A. Enter the Cooperator’s name; B. Enter the Cooperator’s address; C.
Enter the Cooperator’s phone number; D. Enter the Cooperator’s Social Security or Tax Identification Number.
3. Mark the appropriate box to indicate which species is involved in the damage for which this equipment is being assigned. If
other is marked, enter the species in the line provided.
4. In the box provided, enter the date that the equipment/supplies was/were issued.
5. Fill out information about equipment/supplies assigned in the appropriate sections:
5A. If deer or moose fencing equipment or supplies are assigned, enter the quantity and yearly rental of each in the
appropriate columns to the right of the named item.
5B. If coyote or bear fencing equipment or supplies are assigned, enter the quantity and yearly rental of each in the
appropriate columns to the right of the named item.
5C. If other equipment or supplies are assigned enter the name(s) of the items, the quantities, and yearly rentals of each in the
appropriate columns of this section.
5D. Calculate the total of all amounts found in the “yearly rental” column of the table and enter that number here.
5E. Enter the time in years (for which ownership of the equipment/supplies will be accomplished) in the box provided.
Multiply 5D X the number of years you entered in the box and enter that total in the sub-column “5D X YEARS.” This
represents the total amount which will be paid by the Cooperator within a given time frame in order to have ownership of the
equipment/supplies.
6. Read to the Cooperator, or allow the Cooperator to read, the information in this section.
7. Cooperator signs here.
8. WS Representative signs here.
9. Enter the appropriate WS Office address and phone number here. Delete the notation (File Typeapplication/pdfFile TitleMicrosoft Word - WS FORM 68.docAuthorrmyersFile Modified2007-10-19File Created2004-09-29