10-353 Form 10-353 Identification and Credit Information (Indiv

NPS Form 10-354 (08/2016) OMB Control No. 1024-0233

National Park Service Expiration Date: ##/##/####

IDENTIFICATION AND CREDIT INFORMATION (BUSINESS)

(Individual or Sole Proprietor)

NPS Leasing Program

Commercial Services Division

1849 C Street, NW

Washington, DC 20240

I. IDENTIFICATION INFORMATION – INDIVIDUAL OR SOLE PROPRIETOR

Name of Individual

Telephone Number

Alternate Number

     

     

     

Cell

Fax

Tradename, if any

Tax Identification Number (TIN)

Email Address

     

     

     

Address

City

State

Zip Code

     

     

     

     

Contact Person

Role in Providing Business Services

     

     

Years in Business

Current Value of Business

     

     

II. CREDIT INFORMATION

1. Has Applicant ever defaulted from or been terminated from a management contract or lease, or been forbidden from contracting by a public agency or private company? Yes No If “Yes”, provide full details of the circumstances.

     

2. List any Foreclosures, Bankruptcies, Transfers in Lieu of Foreclosure and/or Work-Out/Loan Modification Transactions during the past 10 years. (If none, so indicate) Attach an explanation of circumstances, including resolution, bankruptcy plan, and/or other documentation as appropriate.

Name of Property

City, State

Property Type

Approximate Loan Amount

Lender

Year of Event

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

3. Describe any fines or penalties levied by government agencies during the past 10 years. (If none, so indicate)

     

4. Describe any pending litigation or current lawsuits which if adversely resolved would materially impact the financial position of the Applicant.

     

5. Attach:

Personal Financial Statements Business Financial Statement for most recent 2 years Current credit reports for the individual and business (if available for the business) from a major credit reporting company such as Equifax, Experian, or Dunn & Bradstreet.

6. Attach Resumes of Individual as follows:

• Name

• Address

• Telephone Number

• Fax Number

• Education, Degrees, Licenses, Designations, Special Skills

• Name of Current Employer

• Address

• Nature of Business

• Dates of Employment

• Title of Position Most Recently Held

• Description of Duties and Responsibilities (Include number of people supervised)

• Proposed Role in Lease Operations

• Qualifications for that Role

• Estimated Time per Week Dedicated to that Role

NOTICES

PRIVACY ACT STATEMENT

Authority: Title 54, National Park Service and Related Programs; and the National Environmental Policy Act of 1969.

Purpose: The purpose of the system is to assist, monitor, track and issue leases to individuals and businesses for National Park Service structures and land for activities that are not subject to authorization through a concession contract, commercial use authorization, or similar instrument in federally owned or administered property located within the boundaries of park areas. A leased property must be used for an activity and in a manner that is consistent with the purposes established by law for the park and be compatible with the programs of the National Park Service.

Routine Uses: Records or information contained in this system is not disclosed outside of the Department of the Interior except for those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act; or other authorized routine use when the disclosure is compatible with the purpose for which the records were compiled.

Disclosure: Voluntary, however, failure to provide the requested information may impede our ability to issue a lease contract to the individual or organization.

PAPERWORK REDUCTION ACT STATEMENT

We collect this information under the authority of Title IV of the National Parks Omnibus Management Act of 1998 (Pub. L. 105-391). We use this information to evaluate proposals received in response to leasing opportunities. Your response is required to obtain or retain a benefit. We may not collect or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB control number. OMB has approved this collection of information and assigned Control No. 1024-0233.

ESTIMATED BURDEN STATEMENT

We estimate that it will take you 10 hours to complete a standard Request for Proposal, including 2 hours to complete this form, including time to review instructions, gather and maintain data, and complete and review the form. You may send comments on the burden estimate or any aspect 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 completed form to this address.

RECORDS RETENTION. TEMPORARY. Destroy/Delete 3 years after closure. (NPS Records Schedule, Commercial Visitor Services, (Item 5D)

(N1-79-08-4))