Form 3-202-10 Special Canada Goose - Annual Report

FWS Form 3-202-10 (Rev. 01/2020)
U.S. Department of the Interior

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE

OMB Control No. 1018-0022
Expires ##/##/####

SPECIAL CANADA GOOSE - ANNUAL REPORT
Return to: U.S. Fish and Wildlife Service (USFWS)
BEFORE FILLING OUT THIS FORM, please access the Return Addresses (to obtain the email/
postal mail addresses where this form can be returned).

PERMITTEE: ____________________________________________________________

PERMIT NUMBER:_________________________

ADDRESS: _______________________________________________________________

REPORT FOR CALENDAR YEAR: _______________

Office Use Only
Date Completed Report
rec’d in Regional Office
______/_____/_______
Initials: ________

___________ _________________ REPORT DUE DATE: ________________________
Zip Code
City
State
 Check here if reporting a change of name, address, or contact information
PHONE: ______________________ Email: __________________________________________
________________________________

INSTRUCTIONS: Type or print the information requested below for all birds taken or held under your permit during the year covered by this report and return the completed report to the above address by
the due date. Use of this form is not mandatory, but the same information must be submitted, including a signed certification statement. A supplemental sheet is available, if needed. Filing an annual report
is a condition of your permit. Failure to file a timely report can result in permit suspension. If you had no activity under your permit during the report year, state “No activity” on the form.

MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT.
A. Non-lethal Measures - Describe the non-lethal techniques utilized:

B.

Month Taken

Location
County and State
(required)

Quantity

Birds
Killed

Final Disposition
Nests
(What you did with the birds, eggs, carcasses,
Birds
Destroyed e.g., buried; incinerated; euthanized & donated)
Relocated
**

* * Refers to nests with eggs that are destroyed, addled, oiled, or removed from wild. Do not enter individual eggs, and do not include inactive nests destroyed.
CERTIFICATION: I certify that the information in this report is true and correct to the best of my knowledge. I understand that any false statement herein may subject me to the criminal penalties of
18 U.S.C. 1001.
Signature of Permittee/Principal Officer. (No stamped signatures. Electronic signatures accepted.)

Date ________________________________________________________
Date of signature (mm/dd/yyyy)

FWS Form 3-202-10 (Rev. 01/2020)
U.S. Department of the Interior
PERMITTEE:
B.

SUPPLEMENTAL SHEET - SPECIAL CANADA GOOSE PERMIT ANNUAL REPORT
PERMIT NUMBER:

Month Taken

Location
County and State
(required)

REPORT YEAR: _________

SUPPLEMENTAL PAGE NO: ____

Quantity

Birds
Killed

OMB Control No. 1018-0022
Expires ##/##/####

Final Disposition
Nests
(What you did with the birds, eggs, carcasses,
Birds
Destroyed e.g., buried; incinerated; euthanized & donated)
Relocated
**

* * Includes nests where eggs were destroyed, addled, oiled, or removed from wild. Do not enter individual eggs, and do not include inactive nests destroyed.

OMB Control No. 1018-0022
Expires ##/##/####

FWS Form 3-202-10 (Rev. 01/2020)
U.S. Department of the Interior

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 which affect protected species. The information the individual
provides helps the FWS monitor and report on protected species and assesses 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), 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. 1018-0022.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages:
Original submission - paper-based: 48 minutes (reporting) and 12 minutes (recordkeeping)
Original submission - electronic: 30 minutes (reporting) and 15 minutes (recordkeeping)
These estimates include time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. 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/PERMA (JAO),
Falls Church, VA 22041-3803, or via email at Info_Coll@fws.gov. 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 nonconfidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].