Form 10-354 Business Organization Information (Corporation, Limited

NPS Form 10-354 (Rev.7 /2020)
National Park Service

OMB Control No. 1024-0233
Expiration Date: XX/XX/XXXX

[SIMPLE]
BUSINESS ORGANIZATION INFORMATION
Corporation, Limited Liability Company, Partnership, or Joint Venture

Complete separate form for the submitting business entity and any and all parent entities.
Name of Entity and Trade name, if any
Address
Telephone Number

Fax Number

Email Address

Contact Person
Title
Tax ID#

Ownership
Names and Addresses of those with
controlling interest and key principals of
business

State of Formation

Percentage of Ownership Interests

Date of Formation

Current Value of Investment

Total Interests Outstanding and Type(s):

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NPS Form 10-354 (Rev.7 /2020)
National Park Service

Officers and Directors or General Partners
or Managing Members or Venturers

OMB Control No. 1024-0233
Expiration Date: XX/XX/XXXX

Address

Title and/or Affiliation

Attach the following:
•

Description of relationship of any Offeror-Guarantor to the Offeror with respect to funding and management.

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NPS Form 10-354 (Rev.7 /2020)
National Park Service

OMB Control No. 1024-0233
Expiration Date: XX/XX/XXXX

NOTICES
PRIVACY ACT STATEMENT

Authority: 54 U.S. Code Chapter 1021—Privileges and Leases; 54 U.S. Code § 306121—Lease or exchange.
Purpose: The purposes of the system are (1) to assist NPS employees in managing the NPS Leasing program allowing for
residential and commercial uses within a unit of the National Park System to ensure that business activities are conducted in a
manner that complies with Federal laws and regulations; (2) to monitor resources that are or may be affected by the authorized
residential and/or commercial uses within a unit of the National Park System; (3) to track applicants and holders of leases who are
planning to conduct or are conducting business within units of the National Park System; and (4) to provide to the public the
description and contact information for businesses that provide services in national parks.
Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C.552a(b) of the Privacy Act, records or information
contained in this system may be disclosed outside DOI as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other Federal, state and
local governments, tribal organizations, and members of the general public upon request for names, addresses and phone numbers
of lease holders conducting business within units of the National Park System for the purpose of informing the public of the
availability of the services offered by the lease holder. In addition, records or information contained in this system may be disclosed
outside DOI based on an authorized routine use when the disclosure is compatible with the purpose for which the records were
compiled as described under the system of records notice for this system.
Disclosure: Voluntary, however, failure to provide the requested information may impede our ability to 1) manage the National Park
Service (NPS) Leasing Program allowing for residential and/or commercial uses within a unit of the NPS, 2) monitor resources that
are or may be affected by the authorized residential and/or commercial uses, and 3) provide the public the description and contact
information for businesses that provide services in national parks.
PAPERWORK REDUCTION ACT STATEMENT
We collect this information under the authority of 54 U.S.C. Chapter 1021. We use this information to evaluate a lease proposal.
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 no more than 5 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, 1201 Oakridge Drive, Fort Collins, CO 80525. Please do not send your completed
form to this address.

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