Form 0285-Other Reqs 0285-Other Reqs Other Requirements for Sites

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration OTHER REQUIREMENTS FOR SITES	FOR HRSA USE ONLY
	Grantee Name
	Grant Number			Application Tracking #
Address of physical site for which Applicant is requesting any Federal funding for alternation and renovation, including the installation of equipment:
Identify the current status of the property site (if leased, please answer Question 1B: [_] Owned [_] Leased
If Leased, please check the following: [_] We, _________________________, certify the following: The existing lease will provide the health center reasonable control of the project site; The existing lease is consistent with the proposed scope of project; We are in compliance with all of the terms and conditions affecting the federal interest.
Cultural Resource Assessment and Historic Preservation Considerations (required if ANY Federal funding for alteration and renovation is requested)
A. Is the project facility 50 years or older?			[_] Yes [_] No [_] N/A
B. Does the project include any alteration/renovation to the exterior of the facility?			[_] Yes [_] No [_] N/A
C. Does the project involve renovation to a project facility that is architecturally, historically, or culturally significant?			[_] Yes [_] No [_] N/A
D. Is the site located on Native American, Alaskan Native, Native Hawaiian, or equivalent culturally significant lands?			[_] Yes [_] No [_] N/A