CUA Annual Report with Instructions

PLEASE NOTE: This form is available in printed paper format at the Indiana Dunes National lakeshore Headquarters (address is listed below). For more information, contact Amber Siewin at (219) 395-1859, or send your request for the 10-660 CUA Annual Report with Instructions to:

Indiana Dunes National Lakeshore
Attn: Amber Siewin
1100 N. Mineral Springs Road
Porter, IN 46304

ANNUAL REPORT INSTRUCTIONS

COMMERCIAL USE AUTHORIZATION

A report is required for each Commercial Use Authorization (CUA) issued. These instructions correspond to the numbered questions in Form 10-660.

1. Enter the contact information for the holder and primary contact as written on the CUA.

2. Enter the service the holder is authorized to provide as it appears on the CUA.

3. Enter the number of clients who made use of the commercial services provided under this CUA. Note: If you already submit monthly reports, we only require you to add the monthly reports together.

4. Enter the average number of hours or days a customer spends in the park engaging in your service.

5. Check the box that best describes the level of importance the park plays in providing the commercial services authorized under this CUA.

6. Enter the percentage of time clients spend in the park when engaged in the commercial service authorized under this CUA.

Example: If you take clients on ten (10) mile rafting trips and eight (8) of the ten (10) miles are inside the park, then 80% of the activity takes place in the park OR If you spend four (4) hours on a hike and the last hour is hiking outside the park then you spend 75% of the activity in the park.

7. Enter total gross receipts for the holder (applicant) for the most recent business year. This is the total gross receipts the company brought in, regardless of whether or not the gross receipts are a result of the service provided under this CUA. Enter the total amount in US dollars. Gross receipts will not be made public by the Service except in accordance with law.

8. Enter the portion of gross receipts that are a result of providing the service authorized under this CUA. Enter the total amount in US dollars. Gross receipts will not be made public by the Service except in accordance with law.

Example: If the park is the exclusive destination for clients participating in the services provided, then 100% of the holder’s gross receipts are a result of visiting the park. If the services provided within the park are primary or incidental, or the visit to the park is part of a multi-destination tour, then estimate what percentage of gross receipts are directly attributable to visiting the park.

9. Provide details of any reportable injuries incurred by the holder, the employees of the holder, or clients within the park during the term of this CUA.

10. Check the box to indicate interest in applying for a CUA when this one expires.

11. Signature of business owner or authorized agent.

Attachment A: CUA Annual Report

For Calendar Year: 2017

DUE BY: January 31, 2018

1. CONTACT INFORMATION:

Holder Name:

Contact Person: (if different)

Business Name:

Email: (business)

Mailing Address:

[ ] Winter [ ] Summer

(Street Address)

Email: (contact person)

(City, State, Zip Code) :

Phone: [ ] Winter [ ] Summer

Fax: [ ] Winter [ ] Summer

2. SERVICES PROVIDED: (As it appears on your authorization.)

VISITOR USE INFORMATION

3. VISITORS AND/OR TRIPS:

Enter the number of clients serviced within the park over the past year:

Enter the number of trips (if applicable) your company made to the park over the past year:

4. LENGTH OF STAY: (If applicable)

Enter the average length of time your clients were in the park as a result of the service you provided (if applicable). For day trips, show the average number of hours that you spend in the park per trip. For overnight trips show the average number of nights that you spend in the park per trip from the first travel day to the last day exiting the park.

Average hours per trip:

(Trips that use lodging outside of the park are considered day trips.)

Average number of nights per trip:

(If provided, use table below to report total visitor use numbers.)

5. The park is:

[ ] the EXCLUSIVE destination for your clients. (This means it is the only designation being offered on the trip, not including brief stops along the way. 100% of your trip is a result of your visiting the park.)

[ ] a KEY DESTINATION or a SIGNIFICANT LOCATION. (This means it is one of several sites where your services are provided. Some percentage of your trip is a result of being in the park.)

6. What percentage of the service you provide is a result of visiting the park?

FINANCIAL INFORMATION

7. Enter the total gross receipts for your operation:

8. Enter the portion of the total gross receipts earned that resulting from visiting the park:

(See Instructions)

INJURY INFORMATION

9. Did any reportable injuries occur during your trips this year? [ ] Yes [ ] No

If “Yes”, please use a separate sheet of paper to report the date of the incident and a brief statement of the incident. Include a description of the activity taking place at the time of the injury, the type of injury, and the action taken to provide patient care. Please include the sex and age of the patient (omit the patient’s name). A reportable injury involves any medical incident or injury requiring medical aid beyond Basic First Aid and/or when a request for medical aid/rescue assistance is made. You do not need to send in a report if you have already done so.

RETURNING

10. [ ] Our company plans to return next year. [ ] Our company does not plan to return.

11. SIGNATURE: False, fictitious or fraudulent statements or representations made in this report may be grounds for denial or revocation of the Commercial Use Authorization and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001). Authorized Agents must attach proof of authorization to sign below.

By my signature, I hereby attest that all my statements and answers on this form and any attachments are true, complete, and accurate to the best of my knowledge.

Signature:

Date:

Printed Name:

Title:

NOTICES

Privacy Act Statement

Authority: The authority to collect information on the attached form is derived from 16 U.S.C. 5966, Commercial Use Authorizations.

Purpose: The purposes of the system are (1) to assist NPS employees in managing the National Park Service Commercial Services program allowing commercial uses within a unit of the National Park System to ensure that business activities are conducted in a manner that complies with Federal laws and regulations; (2) to monitor resources that are or may be affected by the authorized commercial uses within a unit of the National Park System; (3) to track applicants and holders of commercial use authorizations who are planning to conduct or are conducting business within units of the National Park System; and (4) to provide to the public the description and contact information for businesses that provide services in national parks.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C.552a(b) of the Privacy Act, records or information contained in this system may be disclosed outside the National Park Service as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other Federal, State, territorial, local, tribal, or foreign agencies and other authorized organizations and individuals based on an authorized routine use when the disclosure is compatible with the purpose for which the records were compiled as described under the system of records notice for this system.

Disclosure: Providing your information is voluntary, however, failure to provide the requested information may impede the processing of your commercial use authorization application.

Paperwork Reduction Act Statement

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), please note the following. This information collection is authorized by The Concession Management Improvement Act of 1998 (54 U.S.C. 101911). Your response is required to obtain or retain a benefit in the form of a Commercial Use Authorization. We will use the information you submit to evaluate your impact to park resources and compliance with park regulations and limitations. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget control number.

Estimated Burden Statement

We estimate that it will take approximately 1.25 hours to prepare a report, including time to review instructions, gather and maintain data, and complete and review the report. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Information Collection Officer, National Park Service, 12201 Sunrise Valley Drive, MS-242 Rm. 2C114, Reston, VA 20192. Please do not submit your form to this address, but rather to the address at the top of the form.

ATTACHMENT A

2017 CUA ANNUAL REPORT

RETAIL SALES: (Food Service, Special Events)

Month | Estimated Number of Customers Served | Gross Receipts Total

April:

May:

June:

July:

August:

September:

October:

Totals (for Season):

GUIDED HIKING/CAMPING/BACKPACKING/SNOWSHOEING TRIPS:

Commercial Use Authorization

National Park Service

INDU

CUA Contact:

Monthly Activity Summary:

Business Phone:

TRIP 1: