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

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

N ational Park Service

HISTORIC PRESERVATION CERTIFICATION APPLICATION
PART 2 – DESCRIPTION OF REHABILITATION

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.

1. 

   NPS Project Number

   Historic Property Name Street City County State Zip Name of Historic District or National Register property

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

2. Project Data (for phased projects, data entered in this section must be totals for entire project)

Date of building Estimated total rehabilitation costs (QRE)

Number of buildings in project Start date (estimated) Completion date (estimated) Application includes phase(s) of phases

Intend to elect IRS 60-month phased rehabilitation

Floor area before / after rehabilitation / sq ft Use(s) before / after rehabilitation / Number of housing units before / after rehabilitation /

Number of low-moderate income housing units before / after rehabilitation /

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 (Sign in ink) Date

Applicant Entity SSN or TIN

Street City State

Zip

Telephone

Email Address

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 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

NPS conditions or comments attached

National Park Service Authorized Signature (Sign in ink)

Historic Property Name _{NPS Project Number}

Property Address

5. 
   

   Number

   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.

Feature Date of Feature

Describe existing feature and its condition

Photo Numbers Drawing Numbers

Describe work to feature

Feature Date of Feature

Number

Describe existing feature and its condition

Photo Numbers Drawing Numbers

Describe work to 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 Internal 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 SSN 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 Officer in order to enable the Secretary of the Interior to gain the benefit of the State review of applications for Federal tax incentives for historic preservation by owners of historic properties. Information collected on this form, including names and all written comments, is subject to disclosure. 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 these burden estimates, or any aspects of this form, to the Information Collection Clearance Officer, National Park Service, 1201 Oakridge Drive, Fort Collins, CO 80525. Please do not send your form to this address.

Records Retention Statement

Permanent. Transfer all permanent records to NARA 15 years after closure. (NPS Records Schedule, Resource Management and Lands (Item 1.A.2) (N1-79-08-1))

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