Electronic Transfer of Payments

OMB Control No. 1024-0021

Expires XX/XX/2017

Privacy Act and Paperwork Reduction Act Notices: The Debt Collection Improvement Act (DCIA) of 1996 (31 U.S.C. § 7701) requires that all new Federal payments certified on or after July 26, 1996, be issued via Electronic Fund Transfer (EFT). This information will be used for the return of any unused portion of the bond posted for your proposed activity. All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. Your response is required to obtain or retain a benefit. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System. We estimate that it will take you 10 minutes to complete this form including time to review instructions, gather necessary information, and review and submit the form. You may provide comments on this information collection to the Service Information Collection Clearance Officer, National Park Service, 1849 C Street, NW. (mailstop 2601), Washington, DC 20240.

ELECTRONIC TRANSFER OF PAYMENTS

Detail Information Sheet

1. Public Gathering Permit No.: ____________________________________________

2. Date of Event: ________________________________________________________

3. Name of Person and/or Organization(s): ___________________________________

4. Contact Person: _______________________________________________________

5. Address: ____________________________________________________________

____________________________________________________________

6. Phone Number: ______________________ FAX Number: ___________________

7. Name of Financial Institution: ___________________________________________

8. Address of Financial Institution: _________________________________________

_________________________________________

9. Account Number at Financial Institution

to be Credited with the Funds: ___________________________________________

10. 9-Digit ABA Identifying Number

for Routing Transfer of Funds: __________________________________________

______________________________ ____________________________ ______

Signature Title Date

Statements must be accurate. The penalty for making false statements is prescribed in 18 U.S.C. § 1001.