Fillable Form 3-200-41a OMB Control No. 1018-0093: (due by (U.S. Fish and Wildlife Service)

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Form 3-200-41a OMB Control No. 1018-0093: (due by (U.S. Fish and Wildlife Service)

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Form 3-200-41a OMB Control No. 1018-0093
Expires 08/31/2020
Rev. 08/2017 Page 1 of 2
Captive-Bred Wildlife Registration Annual Report for Calendar Year ______
(due by March 31 of following year)
This information includes activities of all species/subspecies listed on your registration, even if they are on loan. Note: Attach a year-end inventory of the listed species
(quantity and sex). This form may be copied. Use of this form is not mandatory; however, the same information must be submitted if using an alternate form. Additional
information may be attached to the report.
Permittee: _________________________________________________________ Permit number: ___________________________
Address:____________________________________________________________________________________________________________________________________
(If location/address has changed since last year, indicate new location and date of change)
Provide the following information for all activities for the species/subspecies listed on your registration:
Type Of
Activity
1
Date Of
Activity
2
Quantity
Sex
3
(M/F/?)
Scientific Name
4
Common Name
Permit No./Name/Complete
Address
5
Comments
Example:
Loan out
4/12/02 1.0 Elephas maximus Asian elephant Sunland Zoo and Park Reason for Death
Provide a year-end inventory of all specimens covered under your registration by quantity and sex. Include all specimens that are currently on loan outside your
facility.
E-MAIL or Mail YOUR REPORT TO: Permits@fws.gov (Reference “CBW Annual Report for PRT #MA________” in Subject Line) OR mail to: Division of Management
Authority, Branch of Permits, 5275 Leesburg Pike, MS-IA, Falls Church, VA 22041-3803.
1 Type of activity: Report any activity that affects the number of specimens maintained at your facility -- Births, deaths (include causes and for euthanasia, include reason for euthanasia in comment column) at your facilities, and then
list other types of activities (purchase, sale, loan , donation, gift, trade, export).
2 Date of activity is date it occurred, not necessarily the date specimen was born or transferred.
3 Sex (1.0 = Male; 0.1=female; 0.0.1 = Unknown sex).
4 Include only non-native species listed as Endangered or Threatened under the U.S. Endangered Species Act.
5 CBW Registration number and/or name and address of other CBW registrant involved in the transaction.
Form 3-200-41a OMB Control No. 1018-0093
Expires 08/31/2020
Rev. 08/2017 Page 2 of 2
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 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
Public reporting for this collection of information varies depending on the activity for which a permit is requested. The relevant burden for FWS Form 3-200-41a is
30 minutes 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: BPHC, Falls Church, VA 22041-3803. Please do not send your completed application to this address.
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Form 3-200-41a OMB Control No. 1018-0093: (due by (U.S. Fish and Wildlife Service)

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Completed 15 August 2021

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