APPLICATION INSTRUCTIONS: Applicants must present a completed application, valid state-issued driver license or other suitable photo Identification,
and $5.00 payment in person at many units of the California State Park System (contact parks in advance to ensure availability), or at the Park Pass Sales
Office located at 1416 9th Street, Room 144, Sacramento, CA 95814. Completed applications with required documentation including copy of
photo ID and $5.00 check/money order payable to "CA Department of Parks and Recreation" may be mailed to:
CA State Parks Golden Bear Pass Program, P.O. Box 942896, Sacramento, CA 94296-0001. Please allow 4-6 weeks for processing.
1 Receiving Aid to the Aged, Blind, or Disabled under the provisions of the U. S. Social Security Administration Program for
Supplemental Security Income (SSI) [California State Welfare and Institutions Code Section 12200]. Applicant must show
a current printout of SSI eligibility from U. S. Social Security Administration and photo identification. Applicant must be
at least 16 years of age to qualify.
2
Receiving aid under the CalWORKS Program under the provisions of the California State Welfare and Institutions Code
beginning at Section 11200. Applicant shall be currently covered under Medi-Cal Aid Codes 3A, 3C, 3D, 3E, 3G, 3H, 3L, 3M
3N, 3P, 3R, 3U, 3W, 30, 32, 33, 34, 35, 37, 40, or 42. Applicant must have a case worker at the local county social services
office enter the information below.
3 Aged 62 or over and total monthly income from all sources, including salaries, social security, any old age assistance
payments, or interest and dividend income, does not exceed $935 for a single person, or $1,751 combined monthly income
for married persons or registered domestic partners. Applicant must provide picture identification showing proof of age and
either: (1) present a current reduced fee sport fishing license from the California Department of Fish and Game; or
(2) submit income documents clearly denoting total household income. Acceptable income documents are:
Statement of benefits from Social Security, Veterans Administration, retirement/pension, unemployment
compensation, and/or workmen's compensation; or
Prior year's state, federal, or tribal tax return; or
Income statements or paycheck stubs from the most recent three consecutive months within the calendar year.
DPR 578 (Rev. 12/2012)(Excel 12/1/2012)(Page 1 of 2) DO NOT DUPLICATE APPLICATION
A. Complete the following information:
B. Check one of the following boxes to indicate the provisions under which you qualify:
DEPARTMENT OF PARKS AND RECREATION
State of California - Natural Resources Agency
GOLDEN BEAR PASS APPLICATION
HOME STREET ADDRESS / CITY / STATE / ZIP CODE (no post office boxes)
APPLICANT SIGNATURE
Retain applications for one year from the end of the calendar year, then destroy.
ISSUING OFFICE USE ONLY
Attach the following certification materials to this application with sensitive/confidential information redacted.
NOTE: All certification materials will be retained by California State Parks and cannot be returned.
County Social Services Agency Date Stamp Case Number
INCOME VERIFICATION TYPE
INCOME ELIGIBILITY VERIFIED BY
PASS ISSUED BY
2013 Calendar Year (January-December)
DATE DISTRICT/UNIT
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 of this information is made.
NAME (print or type)
Information on this form is considered personal. See Privacy Notice on Page 2. Terms and Conditions, see Page 2.
PHONE NUMBER
( )
DISTRIBUTION:
Page 1 - California State Parks
Page 2 - Applicant
MAILING ADDRESS / CITY / STATE / ZIP CODE
E-MAIL ADDRESS
Same as Mailing Address
DATE
PASS NUMBER
Case Worker Phone Number
Qualifying Aid Code
INSTRUCTIONS TO CASE WORKER: Applicants must be receiving benefits under one of the qualifying aid codes listed
above. Personal information must be completed prior to case worker sign-off. All required fields below must be completed by
case worker before application is reviewed by CA State Parks. Please redact confidential information from any supporting
documents provided to the applicant.
DATE OF BIRTH SPOUSE/REG. DOMESTIC PARTNER
I certify that the above named applicant is currently receiving benefits under the Qualifying Aid
Case Worker Signature
DRIVER LICENSE/OTHER PHOTO ID NO. (Attach copy)
PAYMENT RECEIVED
Cash Check #_____________
Code listed above.
Printed Name Date
Mail-in (HQ ONLY)
1
2
3
Last 4 Digits CC#_____________
DATE
To qualify under this
first provision you
must be receiving
the specific benefit
called
SUPPLEMENTAL
Security Income
(SSI). If you are not
receiving
SUPPLEMENTAL
Security Income,
please check to see
if you qualify under
the other provisions.
If you have questions regarding the Golden Bear Pass, contact
Information on the application is considered personal. See Privacy Notice below.
TERMS AND CONDITIONS
GOLDEN BEAR PASS PROGRAM
2013 Calendar Year (January - December)
PRIVACY NOTICE
Section 1798.17 of the Civil Code requires this notice be provided when collecting personal information from individuals.
AGENCY NAME
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
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.
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, except Candlestick Point State Recreation Area, 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.
DIVISION
TELEPHONE NUMBER
DEPARTMENT OF PARKS AND RECREATION
State of California - Natural Resources Agency
THE PRINCIPAL PURPOSE(S) WITHIN THE AGENCY FOR WHICH THE INFORMATION IS TO BE USED
APPLICANT'S COPY