Form 10-905 Record of Electronic Payment

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Overview

Form 10-905
Notices

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Sheet 1: Form 10-905

	State						Payment No.			Date*
	LWCF Grant No.	ASAP Account ID (if grant has multiple lines, report draws by line)	Request No.	Select Type:			Amount		Period of Performance**
				Partial, Final or Adjustment					From xx/xx/xxxx	To xx/xx/xxxx
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
	TOTAL (must be same as total requested this date through ASAP)						$0.00
	Submitted By (Name/Title/Office/Agency):
	To (as an e-mail attachment):
	[email protected] [Insert email addresses of other applicable NPS LWCF contact(s)]
	* Date of ASAP request - email submission to NPS Regional Office and NPS WASO should be same date of, but NO LATER THAN one business day after the ASAP request.
	** Period of Performance - Enter the month, day, and year for the start and end of the period covered by this payment, i.e., the time period for the specific work performed and/or costs incurred that are being reimbursed through this ASAP payment (not the overall grant period of performance).
RECORDS RETENTION - PERMANENT. Transfer all permanent records to NARA 15 years after closure. (NPS Records Schedule, National Assistance Programs (Item 8.A.2) (N1-79-08-7))

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Sheet 2: Notices

NOTICES
Paperwork Reduction Act Statement
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), please note the following. This information collection is authorized by the Land and Water Conservation Fund Act of 1965 (54 U.S.C. 2003 et seq.). Your response is required to obtain or retain a benefit. We use this information to provide data input into an NPS project database which provides timely data on projects funded over the life of the program. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget control number. OMB has approved this collection of information and assigned Control Number 1024-0031 to this collection.
Estimated Burden Statement
Public reporting burden for this form is estimated to average 1.5 hours 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, 12201 Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192. Please do not send your form to this address.