WS 66 Nuisance Wildlife Permit [Louisiana]

Clear Form
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 1 5 m i n u t e s 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.

RECORD NUMBER

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES
P.O. BOX 25315
BATON ROUGE, LA 70894
(504) 389-0229

P.O. BOX 494
CROWLEY, LA 70527
(318) 783-0182

OMB Approved
0579-0335
EXP: XX/XXXX

LA
INVESTIGATOR’S INITIALS

RT. 1 BOX 62
BASTROP, LA 71220
(318) 383-2819

REVISIT

NUISANCE WILDLIFE PERMIT (Louisiana)

YES

NO

NUISANCE WILDLIFE PERMIT INFORMATION
COOPERATOR’S NAME (print)

DATE (mm/dd/yyyy)

CATEGORY (select one)

SUBCATEGORY
(use standardized list)

ADDRESS

AGRICULTURE

HUMAN HEALTH AND SAFETY

PROPERTY

NATURAL RESOURCES

PROBLEM SPECIES
B

CITY

COUNTY

STATE

ZIP CODE

M

LAND CLASS
O

F

S

P

O

LOCATION OF ACTIVITY
RESIDENCE

TELEPHONE NUMBER (include area code)

OTHER (specify): ______________________________________________

HOW HANDLED
OFFICE

RESOURCE DAMAGED

DAMAGE TYPE

NO. ACRES/LIVESTOCK DAMAGED (total)

DOLLAR LOSS

WS EFFORT (hours)
TELEPHONE

LETTER

LEAFLET

VISIT

$

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.
NO. OF
ITEMS

COOPERATOR’S SIGNATURE

WS FORM 66
APR 2017

TYPE OF EQUIPMENT

PROPERTY
NUMBER

REPLACEMENT
VALUE

CONDITION

DATE TO BE
RETURNED

DATE

Page 1

ANIMALS TAKEN
NUMBER

SPECIES

COMMENTS

NO. OF
ITEMS

TYPE OF EQUIPMENT RETURNED

PROBLEMS RESOLVED
YES

WS REPRESENTATIVE’S SIGNATURE

PROPERTY
NUMBER

ITEMS DAMAGED
YES

NO

CONDITION

DATE RETURNED

DATE

NO

COMMENTS

WS FORM 66 (REVERSE)

Page 2

PRIVACY ACT NOTICE
5 U.S.C. 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
7 U.S.C. 8351 to 8353, and 16 U.S.C. 667, authorizes officers, agents, and employees of the United States Department of Agriculture (USDA), Animal
and Plant Health Inspection Service (APHIS), Wildlife Services (WS) 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.
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
(1) To cooperative Federal, State, Tribal, and local government officials, employees, or contractors and other parties as necessary to carry out the
program; and other parties engaged to assist in administering the program. Such contractors and other parties will be bound by the nondisclosure
provisions of the Privacy Act. This routine use assists the agency in carrying out the program, and thus is compatible with the purpose for which the
records are created and maintained;
(2) To the appropriate agency, whether Federal, State, local, Tribal, 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;
(3) 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;
(4) 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;
(5) 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 of 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;
(6) To USDA contractors, partner agency employee or contractors, or private industry employed to identify patterns, trends, or anomalies indicative of

fraud, waste, or abuse;
(7) To land management agencies, such as the Bureau of Land Management and the U.S. Fish and Wildlife Service, relating to wildlife damage on
grazing allotments;
(8) To consumer reporting agencies in accordance with 31 U.S.C. 3711(e);
(9) To Federal, State, Tribal, and local regulatory agencies and their employees and contractors who collaborate with Wildlife Services in

implementation of, or agencies that regulate, wildlife management projects or programs, or who have an interest in, or regulate, animal or public health,
or national security;
(10) To Federal or State Government-level representatives of the U.S. Environmental Protection Agency, in compliance with the Federal Insecticide,

Fungicide, and Rodenticide Act (FIFRA) mandate in 7 U.S.C. 136(f, and i thru l), of the location on a cooperator’s property where certain regulated
pesticide devices are deployed or regulated pesticides are applied; and
(11) To the National Archives and Records Administration (NARA) or to the General Services Administration for records management inspections

conducted under 44 U.S.C. 2904 and 2906.
EFFECTS OF FAILURE TO FURNISH INFORMATION
Failure to provide the solicited information will not subject you to penalties or adverse consequences.