State of California - Natural Resources Agency
DISTINGUISHED VETERAN PASS APPLICATION
DEPARTMENT OF PARKS AND RECREATION
For pass terms and conditions, see Page 2.
Distribution: Page 1 - California State Parks; Page 2 - Applicant
California residents that are qualified disabled war veterans, former prisoners of war or recipients of the Medal of
Honor are eligible to receive a Distinguished Veteran Pass, which entitles the holder to the use of all basic State Park
System operated facilities, at no further charge. No fee is required to obtain this pass.
To qualify for the pass, all applicants (veterans) must attach proof of the following as specified in Section B:
1) Photocopy of valid California Driver License or California Identification Card, and 2) Honorable discharge from service
and 3) proof of current California residency, and
4) one of the eligibility criteria listed in Section B-4 for either Disabled War
Veteran, Prisoner of War, or Medal of Honor Recipient eligibility. A name change document such as a marriage certificate
or divorce decree is required if the name on any of the identity documents is different from the name on this application.
Note that all certification material will be confidentially retained by California State Parks and cannot be returned.
If you have questions regarding the Distinguished Veteran Pass, contact
CALIFORNIA STATE PARKS PASS SALES at Passinfo@parks.ca.gov
(Information on this form is considered personal. See Page 2 for Privacy Notice.)
A. Complete the following information:
APPLICANT NAME (print or type: First Name, Middle Initial, Last Name)
DATE OF BIRTH
(mm/dd/yy)
GENDER (Optional)
MALE FEMALE
MAILING ADDRESS APT NO. CITY / STATE / ZIP CODE
PHYSICAL ADDRESS / CITY / STATE / ZIP CODE
(if different from Mailing Address, no P.O. boxes)
EMAIL ADDRESS (Username for ReserveCalifornia™)
PHONE NUMBER CA DRIVER LICENSE / CA I.D. NO.
CHECK HERE IF APPLYING FOR REPLACEMENT PASS
REASON:
APPLICANT'S ORIGINAL SIGNATURE
- I certify under penalty of perjury, the foregoing is true and correct.
E-
Signatures and Photocopies not accepted.
TODAY'S DATE
ALL FOUR CATEGORIES (B)
OF CERTIFICATION ATTACHED
B. Attach the following certification materials with sensitive/confidential information redacted to this application:
(NOTE: All certification material will be confidentially retained by California State Parks and cannot be returned.)
1.
A copy of valid CA Driver License or CA Identification Card showing veteran's current California residence address
(interim/temporary not accepted) and
2.
Proof of Honorable Discharge (e.g. DD Form 214 Member 2-4, or VA "Summary of Benefits Letter"*) and
3.
Proof of current California residency using one of the methods listed below. Dates on acceptable documents to meet
requirements MUST be current and bear the veteran's name and corresponding physical address provided on this
application. Applicant cannot claim multiple state residency for the purpose of this pass.
Current property tax bill showing homeowner's property tax exemption filed in California; OR
California Voter Registration card or affidavit from Registrar of voters; OR
Form 1098T, Tuition Payments Statement showing CA resident in-state tuition paid for most recent tax year; OR
Utility bill (electricity, gas, or cable) statement of charges for most recent three consecutive months; OR
Signed, dated and notarized rental agreement/contract; and
4.
Also include the following attachment(s) for the applicant's specific eligibility qualification as follows:
For DISABLED WAR VETERANS also include all of the following:
1 -
Proof of service during VA recognized wartime periods.
(e.g. DD Form 214 Member 2-4, Certificate of Release or
Discharge from Active Duty or VA "Summary of Benefits Letter"*). Recognized service dates must be listed.
2 - A current letter from the United States Department of Veterans Affairs dated within one year of application stating
the veteran has an overall/combined rating at 50% or greater service-connected disability as determined by the
Veterans Affairs’ combined rating table (e.g. VA "Summary of Benefits Letter"*).
For PRISONERS OF WAR also include:
A letter from the United States Department of Veterans Affairs or copy of personnel records from the
appropriate United States military branch verifying former prisoner of war status.
For MEDAL OF HONOR RECIPIENTS also include:
A letter from the United States Department of Veterans Affairs or copy of personnel records from the
appropriate United States military branch verifying Medal of Honor recipient status.
*"Summary of Benefits Letter" from the United States Department of Veteran Affairs (VA) call (800) 827-1000, voice prompt
"Letters", or visit www.ebenefits.va.gov.
C. Submit this application with your certification material by mail to:
MAIL TO: California State Parks
(Allow 8-10 weeks
Attn: Distinguished Veteran Pass Program
for processing)
P.O. Box 942896
Sacramento, CA 94296-0001
FOR DEPARTMENT USE ONLY
VERIFIED BY DATE ISSUED BY DATE PASS NO.
NOTICE TO EMPLOYEES: The information entered on this form is classified as "personal" under the Information Practices Act (Civil Code
Section 1798). The Department's Legal Office should be consulted before any disclosure is made.
DPR 619 (Rev. 10/2021)(Excel 10/5/2021)(Page 1 of 2)
DISTINGUISHED VETERAN PASS
This is a lifetime pass and is valid for use of the pass holder only. Once pass is received, pass holder may use passcard for applicable
benefits. Although the benefits are lifetime, the pass holder's passcard will need to be renewed every five years. Pass holder agrees to
the Terms and Conditions of this pass and any rules/regulations applicable to California State Parks, as amended from time to time.
Violation may result in pass revocation. Inquire at the location of pass issuance or visit www.parks.ca.gov for the complete list of Terms
and Conditions.
The pass is issued as a personal benefit to the pass holder only. Pass holder may only hold one lifetime discount pass issued
by California State Parks. The pass holder may not lend, loan, reassign, or resell their pass or the privileges allowed by the
pas
s to anyone else. The pass is non-transferable and non-refundable, and cannot be used in conjunction with any other pas
s
and/
or discount. A lost or damaged pass may be replaced only through reapplicatio
n.
The pass is valid unless revoked, at any unit of the California State Park System operated by the California Department of Parks
and Recreation. It is not valid at units operated by federal or local government, private agencies or concessionaires
Information relating to the 5-year renewal process for the passcard will be provided to the pass holder prior to the expiration of
their current passcard. Pass holder should notify the Park Pass Sales Office of any change of name, address, e-mail address,
or
telephone number in order to continue to receive benefits. Pass holder cannot claim multiple state residency for t
he
pur
poses of this pass and associated benefits
.
The pass may be used any day of the week, including holidays, if space is available. Space is not assured - use of facilities is
on a "first-come, first-served" basis when space is available, unless reservations are made in advance. The pass is not valid for
s
pecial events, commercial or group use or for supplemental fees such as additional motor vehicles, sanitation disposal use, etc
.
The pass holder is required to present the Distinguished Veteran Pass (photocopies not accepted) and a valid California Driver
License or California Identification Card showing current California residence address (Interim/temporary not accepted), along
w
ith any campsite reservation or tour ticket, and to pay any supplemental fees at the park
.
The pass may be used for entry of one passenger vehicle with a capacity of nine persons or less where a vehicle day use fee is
collected. (To receive pass benefits at self pay locations, place the pass on the vehicle dashboard where it is visible through the
w
indshield.) The pass may be used for boating for one vessel associated with this vehicle. When a park requires a "ticket pe
r
per
son" admittance such as for museums, swimming pools, tours, etc., the discount applies only to the pass holder
.
The pass may be used for family camping. Only the campsite occupied by the pass holder is subject to the discount. Any
subsequent campsites reserved by the pass holder, but not occupied by the pass holder will be charged full price. Making
m
ultiple overlapping reservations using pass holder's discount is not allowed and will place pass in jeopardy of revocation. T
he
pas
s is not valid for group campsites. The pass holder must be at check-in even when the campsite is reserved in advanc
e.
RESERVATION INFORMATION: Reservations can be made for campsites
through ReserveCalifornia™ by calling toll-free at
1-800-444-7275 (TDD 1-800-274-7275), or for Hearst Castle/Año Nuevo tours by calling toll free at 1-800-444-4445.
No priority can be given to pass holders. Visitors reserving accessible campsites are required to possess a valid Department of
Motor Vehicles (DMV) Disabled Placard or license plate and corresponding identification card issued by DMV. Disabled veterans
possessing a valid disabled veteran's license plate and corresponding identification card issued by DMV also meet the
requirement. All requests for accessible campsites must be made at the time of the reservation.
PRIVACY NOTICE
AGENCY NAME
Department of Parks and Recreation
DIVISION
Strategic Planning and Recreation Services
TITLE OF OFFICIAL RESPONSIBLE FOR MAINTENANCE OF THE INFORMATION
Staff Services Manager II
BUSINESS ADDRESS OF OFFICIAL
P.O. Box
942896, Sacramento, CA 94296-0001
CONTACT EMAIL
passinfo@parks.ca.gov
AUTHORITY WHICH AUTHORIZES THE MAINTENANCE OF THE INFORMATION
Public Resources Code Section 5011.5.
THE FOLLOWING ITEMS OF INFORMATION ARE VOLUNTARY, ALL OTHERS ARE MANDATORY
All information requested on the application is mandatory unless marked as optional.
The applicant will not be issued a Distinguished Veteran Pass.
THE PRINCIPAL PURPOSE(S) WITHIN THE AGENCY FOR WHICH THE INFORMATION IS TO BE USED
The information will be used to determine eligibility for issuance of Distinguished Veteran Passes which entitle the holder to the
use of all basic State Park System operated facilities at no charge except for supplemental fees. Additionally, the information
may be used to determine eligibility for other State Programs and to facilitate communication of such eligibility.
Applications will be retained one calendar year plus prior calendar year for audit purposes and statistical data.
KNOWN OR FORESEEABLE DISCLOSURES OF THE INFORMATION PURSUANT TO CIVIL CODE SECTION 1798.24, SUBDIVISIONS (e) OR (f)
Departmental Audits Office or Human Rights Office.
DPR 619 (Rev. 10/2021)(Excel 10/5/2021)(Page 2 of 2)