Form 3-200-40A Annual Report - ESA Museum Permit

OMB Control No. 1018-0093
Expires XX/XX/XXXX

FWS Form 3-200-40A (Rev. 02/2023)
U.S. Department of the Interior

ESA MUSEUM ANNUAL REPORT
Reporting Requirements. On an annual basis, permittee must provide a report to the Division of Management Authority that may be submitted as a spreadsheet
as described in the table below. Copies of all validated Export/Re-import permits must also be submitted along with the annual report. If there is no activity to
report, permittee must provide a signed statement confirming that no export/re-import activities occurred during the year being reported. If reports are
not received annually, permits may be subject to revocation.

Outgoing Specimen Report
Date Sent

Description
of specimen

Collection
Date

Location
where
obtained

Acquisition
no.

Scientific name
and common name

Receiving
institution, Country

Location
where
obtained

Acquisition
no.

Scientific name
and common name

Sending
institution, Country

Incoming Specimen Report
Date
Received

Description
of specimen

Collection
Date

If you have additional questions, please contact the Division of Management Authority, Branch of Permits, MS: IA; 5275 Leesburg Pike, Falls Church, VA 22041-3803; phone
(703) 358-2104 or fax 703 358-2281.
E-MAIL YOUR REPORT TO: managementauthority@fws.gov (Reference “ESA Museum Annual Report for PRT #MA ______” in Subject Line) or mail to address
on Permit.

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FWS Form 3-200-40A (Rev. 02/2020)
U.S. Department of the Interior

NOTICES

OMB Control No. 1018-0093
Expires 08/31/2023

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
Marine Mammal Protection Act (16 U.S.C. 1361, et seq.), 50 CFR 18; 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. This helps
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
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) in order provide the U.S. Fish and Wildlife Service the information
necessary, under the applicable laws governing the requested activity, for which a permit is requested. 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 applicable 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. 1018-0093.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 20 minutes (electronically) to 30 minutes (paper-based), including 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.
Questions regarding permits from Management Authority should be sent to managementauthority@fws.gov.

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