Form 10-905 Record of Electronic Payment

NPS Form 10-905 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

State

LWCF
Grant No.

ASAP Account ID
(if grant has multiple lines,
report draws by line)

Payment No.

Period of Performance**

Select Type:
Request No.

Partial, Final or
Adjustment

Date*

Amount
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], [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 the same date as, 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))

NPS Form 10-905 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

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. 200301 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, 1201 Oakridge Drive, Fort Collins, CO 80525. Please
do not send your completed form to this address.