Form 10-597 Access Pass - Statement of Disability

OMB Control No. 1024-0252
Expires ##/##/####

NPS Form 10-597 (Rev. 02/2017)
National Park Service

U. S. Department of the Interior --- Bureau of Land Management, Bureau of Reclamation,
Fish and Wildlife Service, National Park Service

U.S. Department of Defense --- Army Corp of Engineers
U. S. Department of Agriculture --- Forest Service

America the Beautiful – The National Parks and Federal Recreational Lands Pass
Statement of Permanent Disability
SITE

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, a designated representative 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: This information is collected to determine adequate proof of permanent disability, citizenship or residency. The
obligation to respond is required to obtain an Interagency Access Pass. A Federal 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. OMB has approved this collection of information and assigned
Control No. 1024-0252.
Public Burden Statement: The public burden for the collection of information is estimated to be 5 minutes per response, including the time for
reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any
aspect of this collection of information may be sent to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Dr., Mil
Stop 242, Reston, VA 20192. Please do not send your form to this address.