Annual Friends Reporting

OMB Control No. 1018-####

Expires ##/##/20##

Annual Friends Reporting

Basic Information

1. Field Station/Complex/Program Name

2. Where is your FWS Regional Office?

Anchorage

Albuquerque Atlanta

Bloomington Denver

Hadley Portland

Sacramento Headquarters

3. Name of Friends Group

4. Name of Person Reporting

5. Email address of person reporting

5. Number of members (if applicable)

The value must be a number

Revenues and Expenditures

From the Friends group's most recent IRS form 990 N, 990 EZ, 990 PF or 990

5. Year the organization's most recent 990 was filed

The value must be a number

8. Total monetary amount donated to the Service (including equipment, supplies, intern funding, capital improvements, etc.)

The value must be a number

Donations to the Fish and Wildlife Service

9. Please describe the donations you made to the Service (name of project or program, amount of funding, brief description) Please list all the projects funded by the amount above. (Example: 1. Water Control Structure, $5,000, The Friends purchased a water control structure for impoundment X to improve habitat for migrating shorebirds. 2. Environmental Education, $2,000, The Friends funded an intern to support EE programming)

10. Accomplishments and highlights - what are you most proud of this year? (This doesn't have to be financial - you can include activities, projects, events, programs, etc.)

NOTICES

PRIVACY ACT NOTICE

The U.S. Fish and Wildlife Service will use your contact information for the purposes of administering Service Agreements with Friends organizations and it may be released to the public to the extent permitted by applicable law. Disclosure is voluntary; however, failure to furnish this information may prevent us from being able to process the service agreement.

PAPERWORK REDUCTION ACT STATEMENT

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects necessary information in order to administer agreements and partnerships with nonprofit Friends groups, 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. 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-####.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information to average 15 hours, 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 survey to this address.