Golden Bear Pass Application Form – Fill Out and Use This PDF

DISTRIBUTION:		State of California - Natural Resources Agency
Page 1	- California State Parks	DEPARTMENT OF PARKS AND RECREATION
Page 2	- Applicant

GOLDEN BEAR PASS APPLICATION

2013 Calendar Year (January-December)

Information on this form is considered personal. See Privacy Notice on Page 2. Terms and Conditions, see Page 2.

APPLICATION INSTRUCTIONS: (NOTE: Completed application packets with all attachments 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 to:

A. Complete the following information:

HOME STREET ADDRESS / CITY / STATE / ZIP CODE (no post office boxes)

Same as Mailing Address

B. Check one of the following boxes to indicate the provisions under which you qualify:

NOTE: Appropriate certification materials with sensitive/confidential information redacted must be included in application packet. (See

"APPLICATION INSTRUCTIONS.")

1				Receiving Supplemental Security Income (SSI) [CA 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. SSI is a Federal income supplement program designed to provide assistance to aged, blind, or
				disabled people with income limitations.
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.

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.

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.

ISSUING OFFICE USE ONLY

Retain applications for one year from the end of the calendar year, then destroy.

INCOME VERIFICATION TYPE			INCOME ELIGIBILITY VERIFIED BY	DATE	PAYMENT RECEIVED
1	2	3			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). The Department's Legal Office should be consulted before any disclosure of this information is made.

DPR 578 (Rev. 3/2013)(Excel 3/11/2013)(Page 1 of 2) DO NOT DUPLICATE APPLICATION

	State of California - Natural Resources Agency	APPLICANT'S COPY
	DEPARTMENT OF PARKS AND RECREATION

GOLDEN BEAR PASS PROGRAM

2013 Calendar Year (January - December)

TERMS AND CONDITIONS

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

62 years of age or over with a monthly income of $935 or less if single, or with a combined monthly income of $1,751 or less if married or in a domestic partnership established 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 yearly fee.

The Golden Bear Pass entitles the bearer and spouse or registered domestic partner entry to most California State Park operated units where vehicle day use fees are collected (except Candlestick Point SRA) at no charge.

Upon receipt of the Golden Bear Pass, the pass holders are advised that the following rules and restrictions apply:

Pass must be renewed each calendar year. Admittance and use subject to available space.

Pass is valid for the use of the pass owner and spouse or registered domestic partner only. Valid unless revoked, non-transferrable and cannot be used in conjunction with any other pass and/or discount.

Pass is valid for one passenger vehicle with a capacity of nine persons or less. Not valid at units operated by local government, private agencies or concessionaires.

Pass holder is required to present the Golden Bear Pass and a valid state-issued driver license (or other suitable photo ID) and to pay any supplemental fees at the park.

To receive pass benefits at self pay locations, display pass on vehicle dashboard where visible through the windshield.

Pass shall not be assigned for profit. Not valid for resale, commercial, industrial, or business operations including but not limted to fleet use or pooling.

Pass is not valid for per-person entry or tour fees (such as museums), boat use, camping, group use or sites, special events, commercial use, or for supplemental fees such as additional motor vehicles, sanitation disposal use, etc.

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.

Applicants must complete the application on Page 1, and present the application, a valid state-issued driver license or other suitable photo ID 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 Dept. Parks and Recreation may be mailed to: CA State Parks, Attn: Golden Bear Pass Program, P.O. Box 942896,

Sacramento, CA 94296-0001. Please allow 4-6 weeks for processing.

If you have questions regarding the Golden Bear Pass, contact

CALIFORNIA STATE PARKS PASS SALES at 1-800-777-0369.

Information on the application is considered personal. See Privacy Notice below.

PRIVACY NOTICE

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.

TITLE OF OFFICIAL RESPONSIBLE FOR MAINTENANCE OF THE INFORMATION

Manager of Visitor Services, Park Operations

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.

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 FOR 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, 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.

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

Departmental Audits Office

DPR 578 (Page 2 of 2)