1. County and WS Employee Information
2. Mark all species to be managed
Species list based on the form contents.
3. Mark all approved components to be used on this project
Components list based on the form contents.
4. Cooperator Acknowledgments

I, the Cooperator, have been informed of the manner in which the damage management components listed in Section 3 will be used, and of the possible hazards associated with their use. APHIS officers, employees, and agents will exercise reasonable precautions to safeguard all persons and to prevent injury to animal life other than those listed, guard against mishandling of control devices and materials, and exercise due caution and proper judgment in all control operations. Cooperator agrees to take reasonable precautions to prevent injury to domestic animals; assume responsibility for injury to property under their control when not the result of APHIS negligence; and that no traps should be left actively deployed and unmonitored over weekends or holidays. This document may be revoked by either party by 30‑day written notice.

5. Special Considerations
6. Landowner / Lessee / Administrator
7. APHIS Representative

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 USDA APHIS Wildlife Services to conduct a program of wildlife services and to enter into agreements for conducting such services. Disclosure of information is voluntary. Information is solicited to execute and implement agreements for control of wildlife damage. Routine uses include sharing with cooperating Federal, State, Tribal, and local officials, contractors, and other parties as necessary to carry out the program; appropriate agencies for law enforcement; the Department of Justice for litigation; courts or adjudicative bodies; and other uses described in the Privacy Act Notice. Failure to provide the solicited information will not subject you to penalties or adverse consequences.

OMB Approved Control Number: 0579‑0335.