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

Notice to Customers Making Payment by Personal Check: When you provide a check as payment, you

authorize us either to use information from your check to make a one-time electronic fund transfer from your

account or to process the payment as a check transaction. When we use information from your check to make

an electronic fund transfer, funds may be withdrawn from your account as soon as the same day we receive

your payment, and you will not receive your check back from your financial institution.

NOTICES

Privacy Act Statement: The Privacy Act of 1974 (5 U.S.C. 552a) provides that you be furnished with the

following information in connection with information required by this application. This information is being

collected to allow the park manager to make a value judgment on whether or not to allow the requested use.

Applicants are required to provide their social security or taxpayer identification number for activities subject to

collection of fees and charges by the National Park Service (31 U.S.C. 7701). Information from the application

may be transferred to appropriate Federal, State, and local agencies, when relevant to civil, criminal or

regulatory investigations or prosecutions.

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork

Reduction Act (44 U.S.C. 3501) to provide the park managers the information needed to decide whether or

not to allow the requested use. All applicable parts of the form must be completed in order for your request

to be considered. You are not required to respond to this or any other Federal agency-sponsored information

collection unless it displays a currently valid OMB control number.

Estimated Burden Statement: Public reporting burden for this form is estimated to average 15 minutes per

response including the time it takes to read, gather and maintain data, review instructions and complete the

form. Direct comments regarding this burden estimate or any aspects of this form to the Information

Collection Clearance Officer, National Park Service, 1849 C Street NW (1237), Washington, D.C. 20240.

Title 18 U.S.C. Section 1001 makes it a crime for any person knowingly and willfully to make to any

department or agency of the United States any false, fictitious, or fraudulent statements or representations as

to any mater within its jurisdiction.

NPS Form 10-931 rev 06/2013

OMB Control No. 1024-0026

Expires 08-31-2016

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