NPS
Form 10-168c (06/2016) OMB Control No. 1024-0009
National
Park Service
HISTORIC
PRESERVATION CERTIFICATION APPLICATION
PART
3 – REQUEST FOR CERTIFICATION OF COMPLETED WORK
Instructions:
This page must bear the applicant's original signature and must
be dated.
NPS
Project Number
1.
Property Name
Street
City
County
State
Zip
Is
property a certified historic structure?
Yes No If yes, date of NPS
certification:
OR date of National Register listing: .
2.
Project Data
Project
Start Date
Project
completed and building placed-in-service date
Estimated
rehabilitation costs (QRE)
Total
estimated costs (QRE plus non-QRE)
Number
of housing units before / after rehabilitation
/
Number
of low-moderate housing units before / after rehabilitation
/
3.
Project Contact
(if different from applicant)
Name
Company
Street
City
State
Zip
Telephone
Email
Address
4.
Applicant
(List all additional owners on next page.)
I
hereby attest that the information I have provided is, to the
best of my knowledge, correct and that I am the owner of the
above-described property within the meaning of "owner"
set forth in 36 CFR § 67.2 (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. Additionally:
If I am not the fee simple owner of the above described
property, then I have checked this box to attest that 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 statement (a)
either is attached
to this application form and
incorporated herein, or has been previously submitted, and (b)
meets the requirements of 36 CFR § 67.3(a)(1) (2011).
Applicant, SSN, or TIN has changed since previously submitted
application.
There are no additional owners within the meaning of "owner"
set forth in 36 CFR § 67.2 (2011).
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 – Request for Certification of
Completed Work (Part 3) for this property and has determined
that:
the completed rehabilitation meets the Secretary of the
Interior’s Standards for Rehabilitation and is consistent
with the historic character of the property
and,
where applicable, the district in which it is located. Effective
the date indicated below, the rehabilitation of the “certified
historic structure” is hereby
designated a
“certified rehabilitation.” This certification is to
be used in conjunction with appropriate Internal Revenue Service
regulations. Questions
concerning specific tax
consequences or interpretations of the Internal Revenue Code
should be addressed to the Internal Revenue Service. Completed
projects may be inspected by an authorized representative of
the Secretary to determine if the work meets the Standards for
Rehabilitation. The Secretary
reserves the right to
make inspections at any time up to five years after completion of
the rehabilitation and to revoke certification, if it is
determined that the
rehabilitation project was not
undertaken as presented by the owner in the application form and
supporting documentation, or the owner, upon obtaining
certification, undertook unapproved further alterations as part
of the rehabilitation project inconsistent with the Secretary’s
Standards for Rehabilitation.
the completed rehabilitation meets the Secretary of the
Interior’s Standards for Rehabilitation. However, because
this property is not yet a “certified historic
structure,” the rehabilitation cannot be designated a
“certified rehabilitation” eligible for Federal tax
credits at this time. It will become a “certified historic
structure” on the date it or the historic
district in which it is located is listed in the National
Register of Historic Places. On that date, the completed
rehabilitation will automatically become a “certified
rehabilitation.” It is the owner’s responsibility to
obtain such listing through the State Historic Preservation
Office. Questions concerning specific tax consequences or
interpretations of the Internal Revenue Code should be addressed
to the Internal Revenue
Service. Completed projects
may be inspected by an authorized representative of the Secretary
to determine if the work meets the Standards for
Rehabilitation. The Secretary reserves the right to make
inspections at any time up to five years after completion of the
rehabilitation and to revoke
certification, if it is
determined that the rehabilitation project was not undertaken as
presented by the owner in the application form and supporting
documentation, or the owner, upon obtaining certification,
undertook unapproved further alterations as part of the
rehabilitation project inconsistent with the
Secretary’s Standards for Rehabilitation.
the rehabilitation is not consistent with the historic character
of the property or the district in which it is located and that
the project does not meet the
Secretary of the
Interior’s Standards for Rehabilitation.
A
copy of this determination will be provided to the Internal
Revenue Service in accordance with Federal law.
Date
National
Park Service Authorized Signature
NPS comments attached
Property
Name
NPS
Project Number
Property
Address
Additional
Owners. Continue
on additional sheets as needed to list all owners.
Name
SSN
or
TIN
Street
Address
City
State
Zip
Name
SSN
or
TIN
Street
Address
City
State
Zip
Name
SSN
or
TIN
Street
Address
City
State
Zip
Name
SSN
or
TIN
Street
Address
City
State
Zip
Name
SSN
or
TIN
Street
Address
City
State
Zip
Name
SSN
or
TIN
Street
Address
City
State
Zip
Name
SSN
or
TIN
Street
Address
City
State
Zip
Name
SSN
or
TIN
Street
Address
City
State
Zip
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 17 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 5
of 7
HISTORIC
PRESERVATION CERTIFICATION APPLICATION