Form 10-168 HCPA Part 1 - Evaluation of Significance

NPS Form 10-168 (06/2016) OMB Control No. 1024-0009

National Park Service

HISTORIC PRESERVATION CERTIFICATION APPLICATION

PART 1 – EVALUATION OF SIGNIFICANCE

Instructions: This page must bear the applicant’s original signature and must be dated. The National Park Service certification decision is based on the descriptions in this application form. In the event of any discrepancy between the application form and other, supplementary material submitted with it (such as architectural plans, drawings and specifications), the application form takes precedence. A copy of this form will be provided to the Internal Revenue Service.

NPS Project Number

     

1. Property Name

     

Street

     

City

     

County

     

State

     

Zip

     

Name of Historic District

     

National Register district certified state or local district potential district

2. Nature of Request (check only one box)

certification that the building contributes to the significance of the above-named historic district or National Register property for rehabilitation purposes.

certification that the building contributes to the significance of the above-named historic district for a charitable contribution for conservation purposes.

certification that the building does not contribute to the significance of the above-named district.

preliminary determination for individual listing in the National Register.

preliminary determination that a building located within a potential historic district contributes to the significance of the district.

preliminary determination that a building outside the period or area of significance contributes to the significance of the district.

3. Project Contact (if different from applicant)

Name

     

Company

     

Street

     

City

     

State

     

Zip

     

Telephone

     

Email Address

     

4. Applicant

I hereby attest that the information I have provided is, to the best of my knowledge, correct. I further attest that [check one or both boxes, as applicable]: I am the owner of the above-described property within the meaning of "owner" set forth in 36 CFR § 67.2 (2011), and/or if I am not the fee simple owner of the above described property, the fee simple owner is aware of the action I am taking relative to this application and has no objection, as noted in a written statement from the owner, a copy of which (i) either is attached to this application form and incorporated herein, or has been previously submitted, and (ii) meets the requirements of 36 CFR § 67.3(a)(1) (2011). For purposes of this attestation, the singular shall include the plural wherever appropriate. I understand that knowing and willful falsification of factual representations in this application may subject me to fines and imprisonment under 18 U.S.C. § 1001, which, under certain circumstances, provides for imprisonment of up to 8 years.

Name

     

Signature

Date

Applicant Entity

     

SSN

     

or TIN

     

Street

     

City

     

State

     

Zip

     

Telephone

     

Email Address

     

NPS Official Use Only

The National Park Service has reviewed the Historic Preservation Certification Application – Part 1 for the above-named property and has determined that the property:

contributes to the significance of the above-named district or National Register property and is a “certified historic structure” for rehabilitation purposes.

contributes to the significance of the above-named district and is a “certified historic structure” for a charitable contribution for conservation purposes.

does not contribute to the significance of the above-named district.

Preliminary Determinations

appears to meet the National Register Criteria for Evaluation and will likely be listed in the National Register of Historic Places if nominated by the State Historic Preservation Officer according to the procedures set forth in 36 CFR Part 60.

does not appear to meet the National Register Criteria for Evaluation and will likely not be listed in the National Register.

appears to contribute to the significance of a potential historic district, which will likely be listed in the National Register of Historic Places if nominated by the State Historic Preservation Officer.

appears to contribute to the significance of a registered historic district if the period or area of significance as documented in the National Register nomination or district documentation on file with the NPS is expanded by the State Historic Preservation Officer.

does not appear to qualify as a certified historic structure.

Date

National Park Service Authorized Signature

NPS Comments Attached

Property Name

     

NPS Project Number

     

Property Address

     

5. Description of Physical Appearance

     

Date(s) of building(s)

     

Date(s) of alteration(s)

     

Has the building been moved?

No

Yes, specify date

     

6. Statement of Significance

     

7. Photographs and Maps. Send photographs and map with application.

NOTICES

Privacy Act Statement

Authority: 26 U.S. Code § 47 - Rehabilitation credit; 26 U.S. Code § 170 - Charitable, etc., contributions and gifts.

Purpose: To enable the Secretary of the Interior to evaluate the historic significance of structures and whether the rehabilitation of such structures preserves their historic character. The primary use of this information by the Secretary of the Interior will be to certify to the Secretary of the Treasury that the applicant is eligible for Federal tax incentives for historic preservation. This application is used by the Interior Revenue Service to confirm that applicants for the tax incentives have obtained the certification concerning historic structures and historic rehabilitations that are required by law.

Routine uses: The information will be used by the National Park Service and the State Historic Preservation Offices and disclosed to the Internal Revenue Service to determine if the applicant is eligible for Federal tax incentives.

Disclosure: Voluntary, however, failure to provide the requested information may prevent or impede you from receiving consideration for the requested benefit.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security Number (SSN) is needed to identify records unique to you. Applicants are required to provide their social security or taxpayer identification number for activities subject to collection of fees and charges by the National Park Service. Failure to disclose your SSN may prevent or delay the processing of your application. The authority for soliciting your SSN is 31 U.S.C. 7701. The information gathered through the use of the SSN will be used only as necessary for processing this application and collecting and reporting any delinquent financial obligations. Use of the social security number will be carried out in accordance with established regulations and published notices of system of records.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) through the State Historic Preservation Offices to enable the Secretary of the Interior to evaluate the historic significance of structures located in historic districts, and to evaluate the rehabilitation of such structures. The primary use of this information by the Secretary of the Interior will be to certify to the Secretary of the Treasure that the applicant is eligible for Federal tax incentives, or that the applicant is not eligible for such incentives. This application is used by the Interior Revenue Service to confirm that applicants for the tax incentives have obtained the certification concerning historic structures and rehabilitations that are required by law. All applicable parts of the form must be completed in order to receive consideration for the requested benefit. A Federal agency may not conduct or sponsor, and a person is not required to respond a collection of information unless it displays a currently valid OMB control number. OMB has approved this collection and assigned it control number 1024-0009.

Estimated Burden Statement

Public reporting burden for this form is estimated to average 27 hours per response including the time it takes to read, gather and maintain data, review instructions and complete the form. Direct comments regarding this burden estimate, or any aspects of this form, to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192. Please do not send your form to this address.

THIS PAGE DOES NOT NEED TO BE PRINTED OUT FOR APPLICATION – FOR APPLICANT RECORDS ONLY.

RECORDS RETENTION - PERMANENT. Transfer all permanent records to NARA 15 years after closure. (NPS Records Schedule, Resource Page 1 of 9

Management And Lands (Item 1.A.2) (N1-79-08-1)).