WS 12 Addendum to a Work Initiation Document

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 minute 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES

OMB Approved
0579-0335
EXP: XX/XXXX

ADDENDUM TO A
WORK INITIATION DOCUMENT

INSTRUCTIONS
1. In Items 1-3, enter the number of the Work Initiation Document for which this addendum is completed, as well as the agreement name and county located.
2. In Items 4-6, enter the Cooperator’s name and telephone number, and the date the addendum is prepared.
3. In Items 7 and 8, enter the additional species that will be addressed and additional components to be used.
4. In Items 9 and 10, enter the Cooperator’s and WS Employee’s signatures and dates signed.
5. Attach to and distribute with the WS Form 12A or 12B work initiation document.
1. WORK INITIATION DOCUMENT NO.

2. AGREEMENT NAME

3. COUNTY

4. COOPERATOR NAME

5. TELEPHONE NUMBER

6. DATE (MM DD YYYY)

7. ADDITIONAL TARGETED SPECIES
K.

S.

AA.

L.

T.

BB.

M.

U.

CC.

N.

V.

DD.

O.

W.

EE.

P.

X.

FF.

Q.

Y.

GG.

R.

Z.

HH.

G.

O.

W.

H.

P.

X.

I.

Q.

Y.

J.

R.

Z.

K.

S.

AA.

L.

T.

BB.

M.

U.

CC.

N.

V.

DD.

8. ADDITIONAL COMPONENTS TO BE USED

9A. LANDOWNER, LESSEE, OR ADMINISTRATOR SIGNATURE

9B. DATE

10A. APHIS WS REPRESENTATIVE SIGNATURE

10B. DATE

WS FORM 12 ADDENDUM
OCT 2017