Fillable GOLDEN BEAR PASS APPLICATION 2020 (California)

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GOLDEN BEAR PASS APPLICATION 2020 (California)

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State of California - Natural Resources Agency
DEPARTMENT OF PARKS AND RECREATION
GOLDEN BEAR PASS APPLICATION
2020 Calendar Year (January - December) - $5.00 Application Fee
To qualify for the Golden Bear Pass, the applicant must currently receive Supplemental Security Income (SSI),
OR receive aid under the CalWORKs program (as defined below), OR be 62 and over and meet certain income limits.
A. Personal Information:
CHECK IF APPLYING TO REPLACE A LOST/STOLEN PASS FROM THIS CALENDAR YEAR.
APPLICANT NAME (Last, First, Middle Initial)
SPOUSE / REGISTERED DOMESTIC PARTNER
PHONE NUMBER
( )
DATE OF BIRTH E-MAIL ADDRESS
MAILING ADDRESS / CITY / STATE / ZIP CODE
HOME STREET ADDRESS / CITY / STATE / ZIP CODE (no post office boxes)
Same as Mailing Address
APPLICANT ORIGINAL SIGNATURE (PHOTOCOPIES NOT ACCEPTED)
I certify under penalty of perjury that the information provided below is true and correct
and that any spouse or registered domestic partner listed in the application has a valid
marriage or civil union license or certificate of registration of domestic partnership.
►
VALID DRIVER LICENSE/OTHER PHOTO ID NO.
(Attach copy if applying by mail)
TODAY'S DATE
B. Attach the following items to this application with sensitive/confidential information omitted:
1. A copy of a valid state issued driver license or photo identification issued by the state, the federal government, or a current
school ID for applicant and spouse or registered domestic partner if named on pass (Interim/Temporary not accepted).
( A name change document, such as a marriage certificate or divorce decree, is required if the applicant name differs from the documentation
provided.)
2. $5.00 application fee: Check/money order payable to CA Dept. of Parks and Recreation, or complete credit/debit card (Visa/
Mastercard/Discover) section.
3.
Required documentation based on selected certification below in Section C, dated within the last year.
C. Check one of the following boxes to indicate the provisions under which you qualify:
1. Receiving Supplemental Security Income (SSI) [CA State Welfare and Institutions Code Section 12200]. Applicant must provide a current
statement of SSI benefits or current benefit verification letter from the U. S. Social Security Administration. Applicant must be at
least 16 years of age.
2. Receiving aid under the CalWORKS Program under the provisions of the California State Welfare and Institutions Code
beginning at Section 11200. Applicant must verify their CalWORKs case is ACTIVE in the month the Golden Bear Pass application
is submitted by providing documentation from their online benefits system or the county social services agency.
3. Single, age 62 or over and average gross monthly income from all sources does not exceed $1,000.23
. (Complete & attach page 2)
4. Married or registered domestic partnership, primary applicant aged 62 or over and combined average gross monthly
income
from all sources does not exceed $1,751.
(Complete & attach page 2)
CREDIT/DEBIT CARD PAYMENT AUTHORIZATION (Mail-in applications only)
CVC No. (3-digit
Card No.:
Expiration:
on back of card):
VISA
MASTERCARD
DISCOVER
I authorize the California Department of Parks and Recreation to charge $5.00 to my credit/debit card. I agree that I will pay for
this purchase in accordance with the issuing bank cardholder agreement.
Name as it appears on card: Signature: Date:
ISSUING OFFICE USE ONLY
Retain applications for one year from the end of the calendar year, then destroy.
INCOME VERIFICATION TYPE
1
INCOME ELIGIBILITY VERIFIED BY DATE
PAYMENT RECEIVED
Cash
Check #
_____________
Last 4 Digits CC#
_____________
PASS ISSUED BY DATE DISTRICT/UNIT
Mail-in (HQ ONLY)
PASS NUMBER
NOTICE TO EMPLOYEES: The information entered on this form is classified as "personal" under the Information Practices Act (Civil Code
Section 1798). When filing in person, supporting documents may be returned to the applicant.
DPR 578 (Rev. 1/2020)(Excel 1/3/2020)(Page 1 of 3)
DO NOT DUPLICATE APPLICATION - DEPARTMENT LEGAL OFFICE SHOULD BE CONSULTED BEFORE DISCLOSURE.
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APPLICANT SPOUSE/REG. DOMESTIC PARTNER
Doc.
Attached
Doc.
Attached
Income Source Annual Gross Income Source Annual Gross
$
$
$
$
$
$
$
$
$
$
$
$
Total Annual Gross Income Total Annual Gross Income
$ $
Total Combined Annual Gross Income:
$
2020 GOLDEN BEAR PASS APPLICATION - Continued Income
Verification
Please read thoroughly before applying under this section.
If you checked box C-3 or C-4 on page one, please choose one of the following two options for income
verification, attach appropriate documentation, and complete and sign the Golden Bear Income
Declaration section at the bottom of page.
I. CURRENT "REDUCED-FEE SPORT FISHING LICENSE: SENIOR - LIMITED INCOME(LI)"
Issued by the California Department of Fish and Wildlife (copy attached).
If verifying under this Section (I), skip Section II and complete Declaration section at bottom.
II. DECLARATION OF TOTAL GROSS ANNUAL INCOME SOURCES
*
State your income in the table below, attach documentation and complete/sign the Golden Bear Income
Declaration below.
Total
gross
income means an
individual's total
income before
taxes or deductions.
This includes ALL sources of income including but not limited to:
Salaries, commission, bonuses, social security, pensions, disbursements from retirement accounts, workers'
compensation benefits, unemployment insurance benefits, rent, interest income, welfare payments, gra nts and
educational allowances.
Total Annual
Gross Income
cannot
exceed:
$12,002.76 for
a single person
or
$21,012 for married
persons or registered domestic partners.
*
Applicant must attach any and all associated documentation providing "Proof of Income". Acceptable
documents include but are not limited to: Statement of benefits from Social Security, Veterans Administration,
retirement/pension, unemployment insurance benefits, and/or workers' compensation benefits; rent
statements, all forms 1099 for income referenced above, Forms W2.
GOLDEN BEAR INCOME DECLARATION (must be completed and signed)
The undersigned hereby certifies, under penalty of perjury, that all information provided in this
application is true and correct, and that he/she meets the Golden Bear Pass Income Limits for the year
in which applying.
NAME OF APPLICANT (Last, First, Middle Initial) NAME OF SPOUSE/REGISTERED DOMESTIC PARTNER (if applicable)
MAILING ADDRESS / CITY / STATE / ZIP CODE
APPLICANT ORIGINAL SIGNATURE (PHOTOCOPIES NOT ACCEPTED)
►
ORIGINAL SIGNATURE - SPOUSE/REGISTERED DOMESTIC PARTNER (if applicable)
►
DPR 578 (Rev. 1/2020)(Page 2 of 3)
DO NOT DUPLICATE APPLICATION - DEPARTMENT LEGAL OFFICE SHOULD BE CONSULTED BEFORE DISCLOSURE.
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signature
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Section 1798.17 of the Civil Code requires this notice be provided when collecting personal information from individuals.
Each individual has the right to review personal information maintained by this agency, unless access is exempted by law.
APPLICANT'S COPY
GOLDEN BEAR PASS PROGRAM
APPLICATION INSTRUCTIONS
APPLICATION INSTRUCTIONS: (NOTE: Completed application packets with all attachments submitted by mail will be
retained by California State Parks and cannot be returned.) Submit completed application and certification material and copy
of valid state-issued driver license or suitable photo Identification, and $5.00 payment (Check/Money Order/Credit) to:
2020 Calendar Year (January - December)
IN PERSON: BY MAIL:
At designated locations of the CA State Park System
(www.parks.ca.gov/passes - contact in advance to ensure availability);
or
at:
Please allow 4-6 weeks for processing. Check/Money order payable to: "CA
Dept. Parks & Recreation" may be mailed with completed packets to:
California State Parks
Attn: Golden Bear Pass Program
P.O. Box 942896
Sacramento, CA 94296-0001
Park Pass Sales Office
1416 9th Street, Room 116
Sacramento, CA 95814
TERMS AND CONDITIONS OVERVIEW
Under the law, any qualifying person receiving Supplemental Security Income (SSI) [CA State Welfare and Institutions
Code Section 12200]; any person receiving aid under the applicable aid codes in the CalWORKS Program; or any person
qualified as listed on page 1, Section C (3&4) in accordance with the California Family Code (beginning at Section 297)
is eligible to receive the Golden Bear Pass upon application and payment of a $5.00 annual fee.
The Golden Bear Pass entitles the bearer and spouse or registered domestic partner entry to most California State Park
ope
rated units where vehicle day use fees are collected at no charge.
Upon receipt of the Golden Bear Pass, pass holder agrees to the Terms and Conditions of this pass; violation could result in
pass revocation. For the complete list of Terms and Conditions inquire at the location of purchase or visit www.parks.ca.gov.
Terms and Conditions include, but are not limited to:
Pass must be renewed each calendar year and is valid for the use of the pass holder and spouse or registered domestic
partner only. Once pass is received, you may use passcard for applicable benefits.
Pass is issued as a personal benefit to the pass holder and spouse or registered domestic partner only (applicable only if
spouse or registered partner is named on passcard). The pass holder may not lend, loan, reassign, or resell their pass or
the privileges allowed by this pass to anyone else, including family members.
Pass holder and spouse or registered domestic partner (if applicable) must abide by any rules and regulations applicable
to California State Parks or to the use of this pass, as amended from time to time.
Pass is valid for one passenger vehicle with a capacity of nine persons or less where a vehicle day use fee is collected.
Not valid at units operated by federal or local government, private agencies or concessionaires. Pass may be used any
day of the week, including holidays, if space is available. Admittance and use subject to available space.
Pass holder is required to present the Golden Bear Pass (photocopies not accepted) and a valid state-issued driver
license or other suitable photo ID (interim/temporary not accepted) and pay any supplemental fees at the park.
To receive pass benefits at self-pay locations, pass holder must clearly display the pass & self-payment receipt on vehicle
dashboard visible through the windshield. Oversized vehicle fees will not be assessed; but, not all parks can accommodate.
Pass is not valid for resale or commercial use, industrial or business operations, including, but not limited to fleet use or
pooling. Pass shall not be assigned for profit and is void if misused.
Pass is not valid for per-person entry or tour fees (such as museums), boat use, camping, group use or sites, special
events, additional/extra vehicle fees, sanitation disposal use or for supplemental fees.
Pass is valid unless revoked. This pass cannot be used in conjunction with any other pass and/or discount, nor can it be
copied or altered in any way. Pass will be cancelled if the pass holder is found not to meet the pass qualifications.
All sales are final. No refunds, replacements or exchanges will be made for any reason including, but not limited to: loss
theft, park closures or environmental conditions such as low water levels, fire, or inclement weather. A lost or damaged
pass may be replaced only through reapplication and payment of $5.00 fee.
For any questions regarding the Golden Bear Pass, contact
CALIFORNIA STATE PARKS PASS SALES at
1-800-777-0369 ext. 2 or 916-653-8280.
Information on the application is considered personal. See Privacy Notice below.
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 Park and Recreation Specialist
BUSINESS ADDRESS OF OFFICIAL
1416 9th Street, Room 116; P.O. Box 942896, Sacramento, CA 94296-0001
TELEPHONE NUMBER
(916) 653-8280
AUTHORITY WHICH AUTHORIZES THE MAINTENANCE OF THE INFORMATION
Public Resources Code Section 5011 (added by Chapter 1303, Statutes of 1982)
THE FOLLOWING ITEMS OF INFORMATION ARE VOLUNTARY, ALL OTHERS ARE MANDATORY
All information requested on the application is mandatory with the exception of credit card information.
THE CONSEQUENCES, IF ANY, OF NOT PROVIDING ALL OR ANY PART OF THE REQUESTED INFORMATION
The applicant will not be issued a Golden Bear Pass.
THE PRINCIPAL PURPOSE(S) WITHIN THE AGENCY F OR WHICH THE INFORMATION IS TO BE USED
The information will be used to determine eligibility for issuance of Golden Bear Passes allowing use of State Park operated facilities where
vehicle day use fees are collected, at no further charge. Applications will be retained one calendar year from the end of the calendar year for
audit purposes, statistical data, and evaluation of the program.
KNOWN OR FORESEEABLE DISCLOSURES OF THE INFORMATION PURSUANT TO CIVIL CODE SECTION 1798.24, SUBDIVISIONS (e) OR (f)
Departmental Audits Office
DPR 578 (Rev. 1/2020)(Page 3 of 3)(Instructions, Terms and Conditions, Privacy Notice) DO NOT DUPLICATE APPLICATION
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GOLDEN BEAR PASS APPLICATION 2020 (California)

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Completed 31 July 2020

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