Form 10-168d HPCA State Historic Preservation Office Review & Recomme

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

N ational Park Service

HISTORIC PRESERVATION CERTIFICATION APPLICATION

STATE HISTORIC PRESERVATION OFFICE

REVIEW & RECOMMENDATION SHEET
PART 1 – SIGNIFICANCE

SECTION 1. APPLICATION INFORMATION					PROJECT NUMBER
Historic Property Name
Property Address
Historic District or National Register Property
☐	National Register District		☐	Certified State or Local District
☐	Property with multiple buildings, including individually-listed properties and properties in a historic district (see Section 6)					SHPO REVIEW SUMMARY
Application received (date)					☐	No outstanding concerns
Additional information requested (date/s)					☐	In-depth NPS review requested
Complete information received (date)					☐	SHPO recommendation differs from applicant’s request
Transmitted to NPS (date)					☐	SHPO recommendation differs from NR documentation on file
Property visited by SHPO staff (date)					☐	Applicant informed of SHPO recommendation
Preliminary consultation (date)
SECTION 2. APPLICATION MATERIALS ☐ Photographs ☐ Historic District Map ☐ Other (list)
☐	For properties with more than one building – map or site plan of the entire property and map or site plan of the portion of the property under applicant’s ownership or control.
SECTION 3. SHPO RECOMMENDATION
, who meets the Secretary of the Interior’s Professional Qualification Standards, has reviewed this application.
☐	The property contributes to the significance of the above-named district or National Register property and is a “certified historic structure” for the purpose of rehabilitation.
☐	The property contributes to the significance of the above-named district and is a “certified historic structure” for a charitable contribution for conservation purposes in accordance with the Internal Revenue Code.
☐	The property does not contribute to the significance of the above-named district.
☐	Insufficient documentation has been provided to evaluate the property.
☐	This application is being forwarded without recommendation.
Preliminary Determinations
☐	The property appears to meet the National Register Criteria for Evaluation and will be nominated individually.
☐	The property does not appear to meet the National Register Criteria for Evaluation and will not be nominated.
☐	The property appears to contribute to the significance of a:
	☐	proposed historic district that appears to meet the National Register Criteria for Evaluation and will likely be nominated.
	☐	registered historic district, but is outside the period(s) or areas of significance as documented in the National Register nomination or district documentation on file with the NPS. The nominated will be amended.
☐	The property is located in a proposed historic district and:
	☐	the property does not appear to contribute to the significance of the proposed historic district.
	☐	the proposed historic district does not appear to meet the National Register Criteria for Evaluation and will not be nominated.
		Date			State Historic Preservation Office Signature

				This is a review sheet only and does not constitute an official determination of the significance of the property.
SECTION 4. ISSUES
☐			Extensive loss or deterioration of historic fabric			☐	Obscured or covered elevation(s)
☐			Substantial alterations over time			☐	Moved property
☐			Significance less than 50 years old			☐	Other (explain)
SECTION 5. HISTORIC DISTRICT OR PRELIMINARY DETERMINATION INFORMATION
The period(s) of significance of the district is .
The property is mentioned in the historic district documentation, section , page .
☐			Supplemental Listing Record requested. The property is located in a registered district, but its current condition is not consistent with the determination that it contributes or does not contribute to the district, as stated in the nomination.
☐			Preliminary Determinations. The state of the nomination for the property/historic district is:
			☐		Nomination was submitted to the NPS on .
			☐		Nomination was submitted to the State Review Board, and will be forwarded to the NPS within months. Draft enclosed.
			☐		Nomination process will likely be completed within thirty (30) months.
			☐		Other, explain .
SECTION 6. SHPO EVALUATION
Describe any problematic issues or concerns. For properties with more than one building, such as a functionally-related complex (identified in Section 1), list all contributing and non-contributing buildings, regardless of ownership, and specify the buildings that are under the applicant’s ownership or control.

SECTION 7. NATIONAL PARK SERVICE EVALUATION
		Date		National Park Service Signature

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.

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 3 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))

THIS PAGE DOES NOT NEED TO BE PRINTED OR SUMBITTED TO NPS