Form 10-168a HPCA Part 2 - Description of Rehabilitation

NPS Form 10-168a (Rev. 07/2019) OMB Control No. 1024-0009

National Park Service Expiration Date XX/XX/20XX

HISTORIC PRESERVATION CERTIFICATION APPLICATION

PART 2 – DESCRIPTION OF REHABILITATION

[PARK]

[Name of Permits Program Office]

[Address]

[City, ST Zip Code]

Telephone: (###) ###-####

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:      

PROPERTY INFORMATION
Property Name
     
Street Address
     
City:
     
County						State	Zip Code
     						     	     
Name of Historic District
     
☐ Listed individually in the National Register of Historic Places; date of listing      
☐ Located in a Registered Historic District; name of district      
☐ Part 1 – Evaluation of Significance submitted?
Date submitted				Date of certification
     				     
PROJECT DATA
Date of building				Estimated rehabilitation costs (QRE)
     				     
Number of buildings in project				Floor area before / after rehabilitation
     				     /       Sq ft
Start date (estimated)				Completion date (estimated)
     				     
Use(s) before rehabilitation				Use(s) after rehabilitation
     				     
Number of housing units before / after rehabilitation				Number of low-moderate income housing units before / after rehabilitation
      /      				      /      
PROJECT CONTACT (if different from applicant)
Name			Company
     			     
Street Address
     
City:			State
     			     
Zip Code	Telephone		Email
     	     		     
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			Company
     			     
Signature			Date
     			     
Applicant Entity			☒ SSN or ☐ TIN
     			     
Street Address
     
City:			State
     			     
Zip Code	Telephone		Email
     	     		     
☐ Applicant, SSN, or TIN has changed since previously submitted application
NPS Official Use only
The National Park Service has reviewed the Historic Preservation Certification Application – Part 2 for the above-named property and has determined that the property
☐ the rehabilitation described herein is consistent with the historic character of the property and, where applicable, with the district in which it is located and that the project meets the Secretary of the Interior’s Standards for Rehabilitation. This letter is a preliminary determination only, since a formal certification of rehabilitation can be issued only to the owner of a “certified historic structure” after rehabilitation work is complete.
☐ the rehabilitation or proposed rehabilitation will meet the Secretary of the Interior’s Standards for Rehabilitation if the attached conditions are met.
☐ the rehabilitation described herein 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
Date :      		National Park Service Signature:      
☐ NPS Conditions or Comments Attached
Property Name					NPS Project Number
     					     
Property Address No. of Permit Requests (For large groups with multiple applications)
     
DETAILED DESCRIPTION OF REHABILITATION WORK Use this page to describe all work or create a comparable format with this information. Number items consecutively to describe all work, including building exterior and interior, additions, site work, landscaping, and new construction
Number				Feature
     				     
Date of Feature:
     
Describe existing feature and its condition
     
Photo Numbers				Drawing Numbers
     				     
Describe work and impact on feature
     
Number				Feature
     				     
Date of Feature:
     
Describe existing feature and its condition
     
Photo Numbers				Drawing Numbers
     				     
Describe work and impact on feature
     
Number				Feature
     				     
Date of Feature:
     
Describe existing feature and its condition
     
Photo Numbers				Drawing Numbers
     				     
Describe work and impact on feature
     

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 51 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.

RECORDS RETENTION. TEMPORARY. Destroy 3 years after closure. (NPS Records Schedule, Protection and Safety (Item 2) Page 1 of 7

(N1-79-08-1))