Fill - Free fillable DPR form 619 DISTINGUISHED VETERAN PASS APPLICATION PDF form

California residents that are qualified disabled war veterans, former prisoners of war or recipients of the Medal of

Honor are eli

ible to receive a Distin

uished Veteran Pass, which entitles the holder to the use of all basic State Park

stem operated facilities, at no further char

e. 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:

)

Photoco

of valid California Driver License or California Identification Card, and 2

)

Honorable dischar

e from service

and

)

roof of current California residenc

, and 4

)

one of the eli

ibilit

criteria listed in Section B-4 for either Disabled Wa

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.

A. Complete the following information:

A copy of valid CA Driver License or CA Identification Card showing veteran's current California residence address

(interim/temporary not accepted) and

Proof of Honorable Discharge (e.g. DD Form 214 Member 2-4, or VA "Summary of Benefits Letter"*) and

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 residenc

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

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 -

Proo

service during VA recognized wartime periods.

(

e.g. DD Form

4 Member

-4,

erti

icate o

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.

C. Submit this application with your certification material by mail or in person to:

MAIL: California State Parks IN PERSON: Park Pass Sales Office

(Allow 8-10 weeks

ttn: Distinguished Veteran Pass Program (Applicant must 1416 9th Street - Room 116

for processing)

P.O. Box 942896 be present.) Sacramento, CA 95814

Sacramento, CA 94296-0001

DPR 619 (Rev. 12/2018)(Excel 12/11/2018)(Page 1 of 2)

If you have questions regarding the Distinguished Veteran Pass, contact

FOR DEPARTMENT USE ONLY

(Information on this form is considered personal. See Page 2 for Privacy Notice.)

*"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.

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

DISTINGUISHED VETERAN PASS APPLICATION

APPLICANT NAME (print or type: First Name, Middle Initial, Last Name)

MAILING ADDRESS

APPLICANT'S ORIGINAL SIGNATURE

- I certify under penalty of perjury, the foregoing is true and correct.

NOTICE TO EMPLOYEES: The information entered on this form is classified as "personal" under the Information Practices Act (Civil Code

(NOTE: All certification material will be confidentially retained by California State Parks and cannot be returned.)

CALIFORNIA STATE PARKS PASS SALES at 1-800-777-0369 ext. 2, or 916-653-8280.

B. Attach the following certification materials with sensitive/confidential information redacted to this application:

For pass terms and conditions, see Page 2.

Section 1798). The Department's Legal Office should be consulted before any disclosure is made.

EMAIL ADDRESS (Username for ReserveCalifornia™)

Distribution: Page 1 - California State Parks; Page 2 - Applicant

PHYSICAL ADDRESS / CITY / STATE / ZIP CODE (if different from Mailing Address, no P.O. boxes)

VERIFIED BY DATE PASS NO.DATEISSUED BY

PHONE NUMBER

()

GENDER (Optional)

TODAY'S DATE

ALL FOUR CATEGORIES (B)

OF CERTIFICATION ATTACHED

CA DRIVER LICENSE / CA I.D. NO.

DATE OF BIRTH

(mm/dd/yy)

MALE FEMALE

CHECK HERE IF APPLYING FOR REPLACEMENT PASS

REASON:

APT NO. CITY / STATE / ZIP CODE

•

Department of Parks and Recreation Strategic Planning and Recreation Services

Staff Park and Recreation Specialist

1416 Ninth Street, Room 116; P.O. Box 942896, Sacramento, CA 94296-0001 (916) 653-8280

Public Resources Code Section 5011.5.

All information requested on the application is mandatory unless marked as optional.

The applicant will not be issued a Distinguished Veteran Pass.

The information will be used to determine eli

ibilit

for issuance of Distin

uished Veteran Passes which entitle the holder to the

use of all basic State Park S

stem operated facilities at no char

e except for supplemental fees. Additionall

, the information

be used to determine eli

ibilit

for other State Pro

rams and to facilitate communication of such eli

ibilit

pplications will be retained one calendar

ear plus prior calendar

ear for audit purposes and statistical data.

Departmental Audits Office or Human Rights Office.

DPR 619 (Rev. 12/2018)(Excel 12/11/2018)(Page 2 of 2)

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.

PRIVACY NOTICE

Section 1798.17 of the Civil Code requires this notice be provided when collecting personal information from individuals.

AGENCY NAME DIVISION

TITLE OF OFFICIAL RESPONSIBLE FOR MAINTENANCE OF THE INFORMATION

BUSINESS ADDRESS OF OFFICIAL

AUTHORITY WHICH AUTHORIZES THE MAINTENANCE OF THE INFORMATION

THE FOLLOWING ITEMS OF INFORMATION ARE VOLUNTARY, ALL OTHERS ARE MANDATORY

THE CONSEQUENCES, IF ANY, OF NOT PROVIDING ALL OR ANY PART OF THE REQUESTED INFORMATION

THE PRINCIPAL PURPOSE(S) WITHIN THE AGENCY FOR WHICH THE INFORMATION IS TO BE USED

KNOWN OR FORESEEABLE DISCLOSURES OF THE INFORMATION PURSUANT TO CIVIL CODE SECTION 1798.24, SUBDIVISIONS (e) OR (f)

Each individual has the right to review personal information maintained by this agency, unless access is exempted by law.

TELEPHONE NUMBER

DISTINGUISHED VETERAN PASS

– Terms and Conditions Overview –

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

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.

Pass holders must self-identify as a Distinguished Veteran Pass Holder when making reservations through

ReserveCalifornia™. 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.

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

pass to anyone else. The pass is non-transferable and non-refundable, and cannot be used in conjunction with any other pass

and/or discount. A lost or damaged pass may be replaced only through reapplication.

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

special 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

with any campsite reservation or tour ticket, and to pay any supplemental fees at the park.

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

multiple overlapping reservations using pass holder's discount is not allowed and will place pass in jeopardy of revocation. The

pass is not valid for group campsites. The pass holder must be at check-in even when the campsite is reserved in advance.

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 the

purposes of this pass and associated benefits.

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

windshield.) The pass may be used for boating for one vessel associated with this vehicle. When a park requires a "ticket per

person" admittance such as for museums, swimming pools, tours, etc., the discount applies only to the pass holder.

Fill Online, Printable, Fillable, Blank DPR form 619 DISTINGUISHED VETERAN PASS APPLICATION Form

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Fillable DPR form 619 DISTINGUISHED VETERAN PASS APPLICATION

Fill Online, Printable, Fillable, Blank DPR form 619 DISTINGUISHED VETERAN PASS APPLICATION Form

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