Form 3-202-56 Annual Report - Special Double-Crested Cormorant

FWS Form 3-202-56 (Rev. 10/2020) OMB Control. No. 1018-0175

U.S. Department of the Interior Expiration Date: ##/##/####

Annual Report – SPECIAL DOUBLE-CRESTED CORMORANT

Return to: U.S. Fish and Wildlife Service

BEFORE FILLING OUT THIS FORM, please access the Return Addresses

(to obtain the email/postal mail addresses where this form can be returned)

Office Use Only

Date Completed Report Rec’d in Regional Office

_____ / _____/ _____

Initials: ____________

Permittee: ­­­­­­­­­­­­­­­­­­­ ___________________________________________________________________________ Permit Number: ___________________

Mailing Address: ______________________________________________________________________ Report for Calendar Year: ___________

City: __________________________________________ State ______ Zip _____________ Report Due Date: __________________

Telephone Number:____________________________ Email Address: ___________________________________________________

Check here if reporting a change of name, address, or contact information

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. You MUST SIGN AND DATE the certification statement for your report to be complete. 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.

For the take of double-crested cormorants, indicate the purpose of the take in the “Purpose” column of the form below using one of the following codes (one code per line):

Aquaculture. Depredation of fish at State- or Tribal-owned or operated aquaculture facilities, including hatcheries

Health. Reduce realized and potential impacts to human health and safety (for example, collisions of airplanes with birds, fecal contamination of urban wetlands)

T/E. Reduce impacts to threatened or endangered species listed under the Endangered Species Act of 1973, and listed species identified in State- or Tribal-specific legislation as threatened or endangered, or, species listed as Species of Greatest Conservation Need in State Wildlife Action Plans

Property. Reduce or prevent damage to State- or Tribal-owned property and assets

Stocked Fish. Reduce or prevent depredation of wild and publicly stocked fish managed by State fish and wildlife agencies or federally recognized tribes and accessible to the public

	Purpose (one code per line) Aquaculture, Health, T/E, Property, Stocked Fish	Non-lethal Methods Implemented	Month Taken	QUANTITY*			Disposition (e.g., buried; incinerated; euthanized & donated)
Location (GPS Coordinates in Decimal Degrees)				Killed	Nests1 Oiled/Addled**	Nests1 Destroyed***

¹For nests, include number of nests where eggs were present, not the number of eggs. Do not include inactive nests (i.e., nests with no eggs).

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 of Signature (mm/dd/yyyy)

SUPPLEMENTAL SHEET - SPECIAL DOUBLE-CRESTED CORMORANT PERMIT ANNUAL REPORT

PERMITTEE:			Permit Number:				Report Year:			Supplemental Page No:
	Purpose (one code per line) Aquaculture, Health, T/E, Property, Stocked Fish	Non-lethal Methods Implemented		Month Taken	QUANTITY*				Disposition (e.g., buried; incinerated; euthanized & donated)
Location (GPS Coordinates in Decimal Degrees)					Killed	Nests1 Oiled/Addled**		Nests1 Destroyed***

¹For nests, include number of nests where eggs were present, not the number of eggs. Do not include inactive nests (i.e., nests with no eggs).

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), 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. 1090-0011.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information averages:

Paper-based submission: 1 hour (reporting) and 16 hours (recordkeeping)

Electronic submission: 45 minutes (reporting) and 16 hours (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 (JAO/3W), 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 non-confidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

Page 1 of 6