Form 10-404A NPS Backcountry/Wilderness Use Permit Hangtag

NOTICES

NP$ Form 10-404A (Rev. 04/2021)
National Park Service

U.S. DEPARTMENT OF INTERIOR
NATIONAL PARK SERVICE
BACKCOUNTRY - WILDERNESS USE PERMIT

PRIVACY ACT STATEMENT
Authority: 54 U.S.C. §100101, NPS Organic Act; 16 U.S.C. 1131-1136, Wilderness Act; 43 U.S.C. §1701 et seq.,16 U.S.C.
§6801-6814, the Federal Lands Recreation Enhancement Act; 36 CFR Part 71, Recreation Fees; 36 CFR 1.6, Permits; and
36 CFR 2.23 Recreation Fees. NPS Backcountry/Wilderness Use Permits may only be issued based on regulations
established in 36 CFR §1.6 and §2.10 (outside of Alaska) and in 36 CFR, Part 13 (in Alaska).

0MB Control No. 1024-0022

The visitor must carry this permit while in the park
When signed, this single-visit pennit authorizes:
Name:

Purpose: To establish and verify an applicant's eligibility for a permit to conduct certain activities within the National
Park System and to process permits for individual members of the public and organizations interested in obtaining a
permit authorizing an activity. Information collected will be used to provide the public and permittees with permit­
related information, to monitor activities conducted under a permit, to analyze data and produce reports to monitor
the use of park resources, to assess the impact of permitted activities on the conservation and management of
protected species and their habitats, and to evaluate the effectiveness of the permit programs. The DOI and NPS may
use the information to meet reporting requirements, to generate budget estimates and track performance, and to assist
park staff with visitors' education, fee collection, resource management and protection, recreational use planning, law
enforcement and public safety personnel for such purposes as emergency contact and search and rescue efforts; to
provide permit holders and participants with information about parks and their partners; and to provide reports or
activities conducted under an issued permit.
Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C.552a(b) of the Privacy Act, the
National Park Service may disclose records or information to Federal, State, territorial, local, tribal, or foreign agencies
to provide information needed to locate an individual or render aid In an emergency; to recover debts owed to me
United States; to respond to a violation or potential violation of the law; in response to a court order and/or discovery
purposes related to litigation; or other authorized routine use when the disclosure is compatible with the purpose for
which the records were compiled.

Address:

City:

Park Name:

Vehicle License Plate State/Number:

Estimated Start Date(mm/dd):

Estimated Finish Date(mm/dd)

Location of Entry:

Location of Exit:

Primary Method of Travel:

Number of People in Group:

Number of Pack or Saddle Stock:

NumberfType of Watercraft:

Communication Device*(Optional)
provider):
Campsite/Zone Name

D Satellite

D Cell

State:

Zip:

D Personal Locator Device (include contact number, type, and

Zone/Site Number

Nights

Disclosure: Voluntary, however, failure to provide the requested information may impede the processing of the
Backcountry/Wilderness Use Permit application for the individual member of the public or organization. Deliberately
and materially making false or fraudulent statements on this form will be grounds for not granting you a
Backcountry/Wilderness Use Permit.
PAPERWORK REDUCTION ACT STATEMENT
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) and 36 CFR 1- 7, 12 and 13
which authorize the National Park Service to require applicants to fill out this form to monitor resources and to protect
visitors. This information is being collected to allow the park management to make value judgments necessary to
enhance the safely and enjoyment of both the visitors and wildlife. Your response is required to obtain or retain a
benefit however, failure to provide the requested information may prevent or delay the processing of your request.
0MB has approved this collection and assigned 0MB Control No. 1024-0022. You are not required to respond to this or
any other Federal agency-sponsored information collection unless it displays a currently valid 0MB control number.
ESTIMATED BURDEN STATEMENT
Public Reporting burden for this form is estimated to average 5 minutes per response, including the time it takes for
reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Comments regarding
this burden estimate or any aspect of this form should be sent to the Information Collection Clearance Officer, National
Park Service, 12201 Sunrise Valley Drive (MS-242) Reston, VA 20192..

Remarks:

My signature indicates I will comply with all park regulations and terms of this permit.

Please practice Leave No Trace Outdoor Ethics

Visitors Signature/ Date:

Issuing Officer's Signature/ Date:

FASTEN THIS TAG TO YOUR PACK, SADDLE, WATERCRAFT, OR TENT
•communication devices may be helpful, but do not guarantee your safety or rescue. It is your responsibility to
accept the risks inherent with your trip and to be self-reliant in the event of an emergency.