WS Form 68 WS Abatement Program Assignment of U.S. Government Prope

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 .0195 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 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 number
2d. ssn/tax i.d.
3. Deer Bear Moose coyote Other
4. issue date
5. table assignment:
5A. deer or moose fencing		QUANTITY	YEARLY RENTAL		5b. COYOTE or BEAR fencing	QUANTITY		YEARLY RENTAL
Electric HV Tape (660’ roll) Small Rolls = $5.00/each/year					Flex-Net (35” X 82’) @ $12.00/year
3/8” X 4’ Fiber rod Posts @ $.30 each/year					Flex-Net (42” X 164’) @ $24.00 each/year
3/8” POST CLIPS (Free)					AN 90 FENCER (9 V BATT.) @ $25.00 each/year
1/2” BY 5’ FIBERROD POSTS @$.75 each/year					ELECTRIC FENCER: V 1000 /D-1B (12V BATT.) @ $35.00 each/year
ELECTRIC FENCER: P 500 / D-1 (110V) @ $25.00 each/year					ELECTRIC FENCER: D-2B (12V BATT.) @ $40.00 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 →
5 E. TOTAL TO OWN AFTER YEARS PAID RENT →								5D X YEARS
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. WS ADDRESS				10. WS PHONE NUMBER
				11. WS EMAIL

WS FORM 68

FEB 2011

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.-11. Enter the appropriate WS Office address, phone number, email here.

Provide a copy of this document to the Cooperator. Consult with your supervisor about distribution of additional copies.

Definitions:

a. Company: A proprietorship, partnership, corporation, or other form of enterprise that engages in business.

b. Corporation: A legal entity that is separate and distinct from its owners.

c. LLC: Limited Liability Company (or Limited Liability Partnership)

d. LLLP: Limited Legal Liability Partnership (or Limited Liability Partnership)

e. LP: Limited Partnership

f. dba: “doing business as” – a formal notice that an individual, company or organization is conducting business under a different name.

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.