Form 10-931 - Application For Special Use Permit Commercial Filming/still Photography - National Park Service Page 3

 

 

Notice   t o   C ustomers   M aking   P ayment   b y   P ersonal   C heck:     W hen   y ou   p rovide   a   c heck   a s   p ayment,   y ou  

authorize   u s   e ither   t o   u se   i nformation   f rom   y our   c heck   t o   m ake   a   o ne-­‐time   e lectronic   f und   t ransfer   f rom   y our  

account   o r   t o   p rocess   t he   p ayment   a s   a   c heck   t ransaction.   W hen   w e   u se   i nformation   f rom   y our   c heck   t o   m ake  

an   e lectronic   f und   t ransfer,   f unds   m ay   b e   w ithdrawn   f rom   y our   a ccount   a s   s oon   a s   t he   s ame   d ay   w e   r eceive  

your   p ayment,   a nd   y ou   w ill   n ot   r eceive   y our   c heck   b ack   f rom   y our   f inancial   i nstitution.    

   

NOTICES  

 

Privacy   A ct   S tatement:     T he   P rivacy   A ct   o f   1 974   ( 5   U .S.C.   5 52a)   p rovides   t hat   y ou   b e   f urnished   w ith   t he  

following   i nformation   i n   c onnection   w ith   i nformation   r equired   b y   t his   a pplication.     T his   i nformation   i s   b eing  

collected   t o   a llow   t he   p ark   m anager   t o   m ake   a   v alue   j udgment   o n   w hether   o r   n ot   t o   a llow   t he   r equested   u se.    

Applicants   a re   r equired   t o   p rovide   t heir   s ocial   s ecurity   o r   t axpayer   i dentification   n umber   f or   a ctivities   s ubject  

to   c ollection   o f   f ees   a nd   c harges   b y   t he   N ational   P ark   S ervice   ( 31   U .S.C.   7 701).     I nformation   f rom   t he   a pplication  

may   b e   t ransferred   t o   a ppropriate   F ederal,   S tate,   a nd   l ocal   a gencies,   w hen   r elevant   t o   c ivil,   c riminal   o r  

regulatory   i nvestigations   o r   p rosecutions.    

 

Paperwork   R eduction   A ct   S tatement:     W e   a re   c ollecting   t his   i nformation   s ubject   t o   t he   P aperwork   R eduction  

Act   ( 44   U .S.C.   3 501)   t o   p rovide   t he   p ark   m anagers   t he   i nformation   n eeded   t o   d ecide   w hether   o r   n ot   t o   a llow   t he  

requested   u se.     A ll   a pplicable   p arts   o f   t he   f orm   m ust   b e   c ompleted   i n   o rder   f or   y our   r equest   t o   b e   c onsidered.  

You   a re   n ot   r equired   t o   r espond   t o   t his   o r   a ny   o ther   F ederal   a gency-­‐sponsored   i nformation   c ollection   u nless   i t  

displays   a   c urrently   v alid   O MB   c ontrol   n umber.  

 

Estimated   B urden   S tatement:     P ublic   r eporting   b urden   f or   t his   f orm   i s   e stimated   t o   a verage   1 5   m inutes   p er  

response   i ncluding   t he   t ime   i t   t akes   t o   r ead,   g ather   a nd   m aintain   d ata,   r eview   i nstructions   a nd   c omplete   t he  

form.     D irect   c omments   r egarding   t his   b urden   e stimate   o r   a ny   a spects   o f   t his   f orm   t o   t he   I nformation   C ollection  

Clearance   O fficer,   N ational   P ark   S ervice,   1 849   C   S treet   N W   ( 1237),   W ashington,   D .C.   2 0240.        

 

Title   1 8   U .S.C.   S ection   1 001   m akes   i t   a   c rime   f or   a ny   p erson   k nowingly   a nd   w illfully   t o   m ake   t o   a ny   d epartment  

or   a gency   o f   t he   U nited   S tates   a ny   f alse,   f ictitious,   o r   f raudulent   s tatements   o r   r epresentations   a s   t o   a ny   m ater  

within   i ts   j urisdiction.    

 

NPS   F orm   1 0-­‐931   r ev   0 6/2013                                  

                                                                                                                                      O MB   C ontrol   N o.   1 024-­‐0026    

 

 

Expires   0 8-­‐31-­‐2016