Interagency Statement of Disability Form

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U. S. Department of the Interior --- Bureau of Land Management, Bureau of Reclamation,

Fish and Wildlife Service, National Park Service

AND

U. S. Department of Agriculture --- Forest Service

America the Beautiful – The National Parks and Federal Recreational Lands Access Pass

Statement of Permanent Disability

S ITE ISSUING STATION

Persons claiming eligibility for the America the Beautiful – the National Parks and Federal Recreational Lands Access Pass who do not have supporting documentation present are required to read, sign and date this form before the pass is issued. If the person is unable to read or sign the statement, someone else may read, date and sign the statement of permanent disability on his or her behalf in the presence of both the applicant and the officer issuing the Access Pass.

Statement of Permanent Disability

I hereby affirm that I am a citizen of or domiciled in the United States, and that I have been medically determined to have a permanent physical, mental, or sensory impairment that severely limits one or more major life activities, and that I have or could obtain written documentation of that disability. Major life activities include functions such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, etc. (Section 504 of the Rehabilitation Act of 1973, as amended, 29 USC § 705(20)).

Federal law at 18 USC 1001 makes it a crime in any matter within the jurisdiction of any department or agency of the United States for any person knowingly and willfully to falsify, conceal, or cover up by any trick, scheme, or device a material fact; to make any materially false, fictitious, or fraudulent statement or representation; or to make or use any false writing or document knowing that it contains a material false, fictitious, or fraudulent statement or entry. Violations of 18 U.S.C. 1001 are punishable by fines of up to $10,000, imprisonment of up to five years, or both.

DATE ISSUED	ACCESS PASS NUMBER	NAME (PRINTED)	SIGNATURE	ISSUING OFFICER INITIAL

Paperwork Reduction Act Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The time required to complete this information collection is estimated to average five minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have questions, comments or suggestions regarding this collection of information, please contact the National Park Service WASO Fee Management Office at 1849 C St. NW Org Code 2608, Washington DC, 20240.