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APPLICATION
An Equal Opportunity/Armative Action Agency Program
What is the
Lifetime Liberty Pass?
The Lifetime Liberty Pass permits New York State
veterans with a 40 percent or greater service-connect-
ed disability, discounted use of parks, historic sites, and
recreational facilities operated by the New York State
Oce of Parks, Recreation and Historic Preservation
and the New York State Department of Environmental
Conservation. For a description of these facilities visit
www.parks.ny.gov and www.dec.ny.gov.
The pass holder may have free or discounted use
of facilities operated by these oces, for which there
is normally a charge — for example, parking, camping,
greens fees, swimming.
The Lifetime Liberty Pass is not valid for waiver of
fees such as those for seasonal marina dockage, group
camp or cottage rental, performing arts programs,
consumables (i.e. firewood, electric, or gas), campsite/
cabin amenities, reservations and registrations as well
as some services or locations operated by an outside
concessionaire.
Qualifications and requirements are described within
the application.
The Lifetime Liberty Pass does not expire. If lost or
damaged, please call 518-474-2324.
The Oce of Parks, Recreation and Historic Pres-
ervation is authorized to collect this information by
Section 3.09 of the Parks, Recreation and Historic
Preservation Law. It will be used to determine your
eligibility and to process your application. If the informa-
tion you provide is not complete, it will not be possible
to process your application. The information will be
maintained by the Regional Programs and Services
Bureau, State Parks, Albany, NY 12238, 518-474-2324,
TTY/TDD through 711 Relay Service. The information
may also be used to contact you about this and other
programs of the New York State Oce of Parks, Rec-
reation and Historic Preservation.
RS 8 3/21
parks.ny.gov dec.ny.gov
To ensure that your application can be
approved for processing please be sure
that all of the items below are included
when submitting your application.
√
Complete the Applicant Information (Part A)
√
Include a copy of your NYS Driver’s License or
Non-Driver ID card (Part B)
√
Enclose certification from the U.S. Veterans
Administration showing a 40% or greater
service-connected disability (Part C)
√
Sign and Date the Authorization and
Certification (Part D)
• This application cannot be processed on site at
any location.
Email this application, enclosing all
required materials to:
Accesspass@parks.ny.gov
Or Mail to:
Access Pass
New York State Parks
Albany, NY 12238
Please allow 2 - 4 weeks for processing
of this application
For questions contact our oce during
regular business hours.
518-474-2324
TTY/TDD through 711 Relay Service
Lifetime Access for Veterans with Disabilities
LIFETIME
LIBERTY PASS
Lifetime Liberty PassLifetime Liberty Pass
Lifetime Access for Veterans with Disabilities
John Veteran
12345-VA
Lifetime Liberty Pass
Guidelines for Use
Please provide a copy of one of the following which must be in the name of the applicant:
• A copy of a currently valid New York State Driver License or Non-Driver Identification card (do not send original).
• A New York State tax return (IT 201 or IT 150) for the current, or if not yet filed, the preceding tax year (financial information may
be hidden).
A. APPLICANT INFORMATION
Birth Date
First Name
C. ATTACH CERTIFICATION issued within ONE YEAR of this application’s date.
PLEASE NOTE:
The following are NOT acceptable proofs of disability:
• New York State Handicapped Parking Permit
• Veterans Administration medical treatment card
• Military Identification Card
Street Address
Mailing Address (if dierent than street address)
Telephone Number
Month Day Year
Last 4 Digits of Social Security
X X X X X
Last Name
City or Town State Zip Code
NY
B. RESIDENCY REQUIREMENT
D. AUTHORIZATION & CERTIFICATION
I authorize the release of any pertinent medical information needed to process this application. I certify that the information provided is true
to the best of my knowledge and believe and understand that any person who knowingly files a statement containing any materially false in-
formation, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act. ANY FALSE
STATEMENT MADE HEREIN IS PUNISHABLE AS A CLASS “A” MISDEMEANOR PURSUANT TO SECTION 210.45 OF THE PENAL LAW.
Applicant Signature Date
OR
Disability Code ______ Denial Code (s) ______
Approved By ______ Denied By ______
INCOMPLETE APPLICATIONS WILL BE RETURNED
Applicant must complete Sectio
ns A through D
VA
City or Town State Zip Code
Ofce Use Only
• VA Veteran who has a disability: Certification from the United States Veterans Administration or the New York State Division of Veterans Aairs
t
hat the applicant is a veteran of the wars of the United States with a 40% or greater service connected disability as certified by the United
States Veterans Administration, or who has at any time been awarded by the Federal government an allowance towards the purchase of an
automobile or who is eligible for such an award.
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Completed 14 June 2022

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