WS Form 66 Nuisance Wildlife Permit [Louisiana]

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 valid OMB control number. The valid OMB control number for this information collection is 0579-0335. The time required to complete this information collection is estimated to average .044 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.

OMB Approved 0579-0335 EXP XX/XXXX

United States Department of Agriculture Animal and plant health inspection service Wildlife services

record number: LA

p.o. box 25315 Baton rouge, la 70894 (504) 389-0229

p.o. box 494 CROWLEY, la 70527 (318) 783-0182

rt. 1 box 62 BaSTROP, la 71220 (318) 383-2819

Investigator’s initials

Nuisance wildlife permit (Louisiana)

Revisit Yes No

Nuisance wildlife permit information

Cooperator’s Name (Print)

DATE

Category (“X” one)

subcategory (Use Standardized list)

Agriculture

Human Health and Safety

Property

Natural Resources

Address

Problem species B M O

Land class F S P O

City

county

state

zip code

Location of activitty

Residence

Phone number (Include Area Code) ( )

Other (Specify): _______________________________________________

Resource damaged

Damage type

how handled Office Telephone Visit Letter Leaflet

WS EFFORT (Hours)

Number Acres/livestock damaged (Total)

Dollar loss $

Pursuant to an agreement between USDA/Wildlife Services and the Louisiana Department of Wildlife and Fisheries, you are authorized to take ______________________ ________________________________________________________________________________________________________________by the following method(s) only: Live trap and Relocate Trap Shoot Other (Specify): ____________________________________________________________________________ Shooting *when authorized) may be done only during legal shooting hours. Animal carcasses should be disposed of by burial, burning, or donation to a university museum. Please use the back of this form to list the number and species of animals taken. This information must be mailed (upon expiration of this permit) to the Game Division of the Louisiana Department of Wildlife and Fisheries, P.O. Box 98000, Baton Rouge, LA 70898.

This permit expires

Authorizing signature

You have been provided a Federal Fish and Wildlife License/Permit Application. You MUST request permission from the U. S. Fish and Wildlife Service to take migratory birds.

recommendations/comments

Expendable items distributed

Number of Items

Description

Temporary assignment of government property to private individuals

The equipment listed below is temporarily assigned to the cooperator whose signature is affixed below for the purpose of controlling nuisance animals. The cooperator has received instructions on its proper use and accepts full responsibility for the safe operation of the equipment and agrees to release the Animal and Plant Health inspection Services of their designated agents, from any liability for personal injury, injury to others, or property damage arising from operation and use of the assigned equipment or from any animal captured. The assigned equipment will be returned on or before the date listed below unless other arrangements have been made. Should the equipment be damaged, lost, or stolen, it will be replaced by the cooperator or reimbursement made at the value listed below.

Number of items

Type of equipment

Property number

Replacement value

Condition

Date to be returned

/ /

/ /

/ /

/ /

Cooperator’s signature

Date

WS FORM 66 Page 1

FEB 2011

Animals taken
Number		Species
Comments
Record of property return
Number of items	Type of equipment returned			Property number	items damaged		Condition	Date returned
					yes	no
								/ /
								/ /
								/ /
								/ /
problems resolved Yes No			WS Representative’s signature				Date
comments

WS FORM 66 Page 2

Privacy Act Notice

Title 5. United States Code, Section 552a(e)(3) requires that each agency that maintains a system of records provide each individual from whom the agency solicits information with the following information.

Authority for Requesting Information

Title 7, United States Code (USC), Section 426-426c, and Title 16 USC, Section 667, authorizes officers, agents, and employees of the USDA, APHIS, Wildlife Services to conduct a program of wildlife services and to enter into agreements with States, local jurisdictions, individuals, and public and private agencies, organizations, and institutions for the purpose of conducting such services. Further, 5 USC 552a authorizes USDA, APHIS, Wildlife Services to collect information about private individuals for its system of records pursuant to the conduct of program activities with those private individuals.

Nature of Your Disclosure of Information

Disclosure of information solicited by USDA, APHIS, Wildlife Services is voluntary.

Principle Purpose for Which the Information is Solicited

Information is solicited from you for the purpose of executing and implementing agreements for control of wildlife damage.

Routine Uses Which May be Made of the Information

The routine uses which may be made of the information are:

Routine use 1 provides for disclosure to the cooperative State government officials, employees, or contractors, as necessary to carry out the program.

Routine use 2 provides for the referral to the appropriate agency, whether Federal, State, local, or foreign, charged with responsibility of investigating or prosecuting a violation of law or of enforcing, implementing, or complying with a statute, rule, regulation, or order issued pursuant thereto, of any record within this system when information available indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and either arising by general statute or particular program statute, or by rule, regulation, or court order issued pursuant thereto;

Routine use 3 permits disclosure to the Department of Justice when the Agency, or any component thereof, or any employee of the Agency in his or her official capacity, or any employee of the Agency in his or her individual capacity where the Department of Justice has agreed to represent the employee, or the United States, in litigation, where the Agency determines that litigation is likely to affect the Agency or any of its components, is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice is deemed by the Agency to be relevant and necessary to the litigation; provided, however, that in each case, the Agency determines that disclosure of the records to the Department of Justice is a use of the information contained in the records that is compatible with the purpose for which the records were collected;

Routine use 4 permits disclosure for use in a proceeding before a court or adjudicative body before which the Agency is authorized to appear, when the Agency, or any component thereof, or any employee of the Agency in his or her official capacity, or any employee of the Agency in his or her individual capacity where the Agency has agreed to represent the employee, or the United States, where the Agency determines that litigation is likely to affect the Agency or any of its components, is a party to litigation or has an interest in such litigation, and the Agency determines that use of such records is relevant and necessary to the litigation; provided, however, that in each case, the Agency determines that disclosure of the records to the court is a use of the information contained in the records that is compatible with the purpose for which the records were collected;

Routine use 5 permits disclosure to a congressional office in response to a request from that office for the record of an individual made at the request of that individual;

Routine use 6 permits disclosure to the Comptroller General or any of his authorized representatives in the course of their duties at the Government Accountability Office; and

Routine use 7 permits disclosure to a consumer reporting agency in accordance with section 31 U.S.C. 3711(e).

Routine use 8 permits disclosure to appropriate agencies, entities, and persons when the Agency suspects or has confirmed that the security or confidentiality of information in the system of records has been compromised; the Agency has determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests, a risk of identity theft or fraud, or a risk of harm to the security or integrity of this system or other systems or programs (whether maintained by the Agency or another agency or entity) that rely upon the compromised information; and the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with the Agency’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm.

Effects of Failure to Furnish Information

Failure to provide the solicited information will not subject you to penalties or adverse consequences.