Attachment K

Form Approved
OMB No. 0937-0191
Exp. Date 04/30/2021

APPLICATION
INSTRUCTION BOOKLET

FOR THE

DEPARTMENT OF HEALTH & HUMAN SERVICES
FEDERAL REAL PROPERTY ASSISTANCE PROGRAM
HOMELESS ASSISTANCE

PROGRAM SUPPORT CENTER
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0937-0191. The time required to complete this information collection is estimated to
average 200 hours/ minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports
Clearance Officer.

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TABLE OF CONTENTS
TABLE OF CONTENTS ..................................................................................................................... 2
PROGRAM FACT SHEET.................................................................................................................. 3
PROGRAM CONDITIONS SUBSEQUENT TO TRANSFER ................................................ 4
CRITERIA FOR APPLICATION REVIEW .......................................................................................... 5
APPLICATION INSTRUCTIONS......................................................................................................... 6
INITIAL APPLICATION CHECKLIST ............................................................................................. 7
APPLICATION PART I FORMAT ...................................................................................................... 8
ATTACHMENT A ........................................................................................................................... 15
ATTACHMENT B ........................................................................................................................... 16
ATTACHMENT C ........................................................................................................................... 18
APPLICATION PART II ........................................................................................................... 22
ATTACHMENT D ........................................................................................................................... 25
INTRODUCTION ...................................................................................................................................................... 25
INSTRUCTIONS ........................................................................................................................................................ 25
BASIS FOR DETERMINATION AND DOCUMENTATION ........................................................................................... 26
QUESTIONS ............................................................................................................................................................. 27

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PROGRAM FACT SHEET
•

•

•

•
•

•

The Federal Real Property Assistance Program (FRPAP), under the authority of
40 U.S.C. § 550 and 42 U.S.C. § 11411 and 45 C.F.R. Parts 12 and 12a, transfers surplus
real Federal property to eligible State and local governments and non-profit organizations
for various public benefit purposes: Public Health and assisting the Homeless.
In 1987 Congress passed the McKinney-Vento Homeless Assistance Act, of which Title
V utilizes the existing FRPAP structure to make the conveyance of surplus properties to
providers of homeless assistance services a priority over other means of property disposal
to non-Federal entities.
As amended, Title V of the McKinney-Vento Act makes excess/surplus Federal property
found suitable by the U.S. Department of Housing and Urban Development (HUD)
available to assist persons experiencing homelessness at no cost, not including fees or
costs in connection with the transfer of the property (e.g., local recordation fees).
Property found excess due to Base Realignment and Closure (BRAC) is not included in
the scope of Title V; rather, it is under the scope of a Local Redevelopment Authority
(LRA).
HHS has overseen the transfer of properties for a wide range of homeless uses, including,
but not limited to:
o Emergency shelter;
o Women’s shelter;
o Transitional housing;
o Permanent supportive housing (long-term housing linked to appropriate
supportive health and/or social services);
o Mental health services;
o Healthcare services;
o Substance abuse services;
o Homeless services for veterans;
o Food banks; and
o Administrative offices for organizations that support persons experiencing
homelessness.
Please note that services provided to non-homeless, low-income individuals are not
eligible programs; the clientele served must be homeless as defined at 42 U.S.C. § 11302.

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PROGRAM CONDITIONS SUBSEQUENT TO TRANSFER
HHS transfers real property by quitclaim deed or lease, at the discretion of the applicant,
which are subject to the following conditions contained in the transfer document:
1. Transferee must utilize the property in accordance with their approved application for a period of
thirty (30) years (or another negotiated term for leases) from the date of the initial transfer document.
2. Where construction or major renovation is not required or proposed, transferee must put the Property
into use within twelve (12) months from the date of transfer. Where transferee contemplates
construction or major renovation at the time of transfer, transferee must put the Property into use
within thirty-six (36) months from the date of transfer.
3. Transferee may not sell, lease, sublease, or otherwise encumber the property without prior written
consent of the transferor.
4. Transferee must submit annual utilization reports. NOTE: Transferee will be required to report
related to the occurrence of any incidents on the transferred property during the reporting period
which would had the potential to affect the value of the transferred property and/or expose Transferee
and/or the federal government to liability.
5. Transferee must comply with section 606 of the Federal Property and Administrative Services Act of
1949; the Fair Housing Act (42 U.S.C. § 3601-19); Executive Order 11063 (Equal Opportunity in
Housing), as applicable; Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d to d-4)
(Nondiscrimination in Federal Assisted Programs); Title IX of the Education Amendments of 1972
(20 U.S.C. §1681); the prohibitions against discrimination on the basis of age under the Age
Discrimination Act of 1975 (42 U.S.C. § 6101-07); the prohibitions against otherwise qualified
individuals with handicaps under Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794);
and the Architectural Barriers Act Accessibility Standards (ABAAS) (36 CFR 1191, Appendices C
and D); all implementing regulations of the above listed statutes, including all requirements imposed
by or pursuant to the regulations of the Transferor (45 CFR Parts 12, 12a, 80, 84 and 91) issued
pursuant to said Acts and now in effect.
6. Transferee must remain tax supported or a nonprofit tax-exempt organization under section 501(c)(3)
of the IRS Code of 1986, as amended, throughout the period of restrictions.

Upon breach of any of the conditions contained in the transfer document, title may, at the
Government’s sole discretion, revert to the Government. In regards to property transfers
made by deeds, the grantor may also permit the grantee to abrogate the conditions by:
1. Obtaining the consent of the grantor, or its successor in function, and
2. Making payment to the United States of America of 1/360th of the fair market value of the property
as of the date of such requested abrogation, exclusive of the value of improvements made by the
grantee to the extent that they add to the value of that portion of the Property to be released, for each
month of the period to be abrogated. Grantee will not earn credit (discount) for any time the property
was not used in accordance with the approved application or another use as approved by HHS.
NOTE: Other covenants and conditions may be required in the transfer document for such concerns as
lead-based paint, environmental condition(s) of the property, historical preservation issues, etc.

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CRITERIA FOR APPLICATION REVIEW
Organizations are eligible to submit applications if they are a State, a unit of local government, or a
private non-profit organization (must be a registered 501(c)(3) tax-exempt organization) that serves
persons experiencing homelessness. HHS evaluates applications from eligible organizations on the basis
of the following factors:
•

PART I - (Initial Application)
Services offered – The extent and range of proposed services such as meals, shelter, job training,
and counseling and the number of eligible people that will be served, as well as the legal ability to
provide the proposed services.
a. The above is not an exhaustive list; other services are considered as they are proposed,
including administrative services, as long as the program serves persons experiencing
homelessness.
b. Services provided to low-income, non-homeless clients are not eligible programs; the
clientele served must be homeless as defined at 42 U.S.C. § 11302.
c. Where a transfer by deed is requested, the proposed program must comply with all
applicable federal, state and local legal requirements including zoning.

•

Implementation Time – The amount of time necessary for the proposed program to become
operational.
a. Please note that all transfer documents include a clause that requires full utilization of the
property within twelve (12) months from the date of transfer, unless major
construction/renovation is required, in which case the transferee would have thirty-six
(36) months from the date of transfer.
b. If the applicable time limitation is not met, the transferee shall, at HHS’ sole discretion,
either commence payments in cash to HHS for each month thereafter during which the
proposed use has not been implemented in accordance with 45 C.F.R. 12.3(c) or take
such action as set forth in 45 C.F.R. Part 12.12 and as deemed appropriate by the
Department.

•

Need – The demonstrated need for the proposed services within the proposed service area and
applicant’s demonstrated need for the requested property.
a. The demonstrated need for a proposed program is measured against the current homeless
services provided and the number of homeless persons residing in the local community.
An applicant must demonstrate that there is an unmet need in the local community for the
services it intends to provide. The proposed property must be fully utilized, which
includes making the best use of the entire property and any existing or proposed
structures, including full use of available building space.

•

Experience – Organization’s demonstrated prior experience in operating similar programs at the
scale being proposed and/or ability to overcome any gaps in related experience.
PART II - (Final Application)

•

Financial Ability – The adequacy and certainty of funding that will be available to develop and
operate the program fully and properly, and to operate and maintain the facility.

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APPLICATION INSTRUCTIONS
FEDERAL REAL PROPERTY ASSISTANCE PROGRAM
HOMELESS ASSISTANCE
(ONSITE)
Please provide complete responses to each item in the application format. For ease of reference,
begin each response with its respective item number and heading. In an instance where a request
for information is not applicable to your program, please include the heading and state “Not
Applicable.” A good presentation of an application reflects a well thought out plan and objective
for the property.
At HHS’ discretion, applications deemed incomplete will either result in a disapproval of the
application or a request for additional information. It is to the applicant’s benefit to err on the
side of providing too much information as opposed to omitting information or not providing
enough detail. It is the applicant’s responsibility to ensure that its application presents all the
information requested in a detailed, accurate, and complete manner.
Complete responses to the items contained in Part I of the application (Initial Application) are
due to HHS within seventy-five (75) calendar days of HHS’ receipt of an expression of interest.
The applicant’s due date is specified in the letter which transmitted this application instruction
booklet.
Should HHS determine an applicant meets the review criteria in PART I of the application, HHS
will request that the applicant complete the items in PART II of the application. The applicant’s
responses to the items in PART II of the application are due to HHS within forty-five (45)
calendar days from HHS’ official notice, for review and final determination.
Applications should be submitted electronically as Personal Document Files (PDFs) by email to
[email protected]. It is acceptable to submit large files in multiple emails if needed. If the
applicant is unable to submit its application electronically, the applicant should contact staff on
(301) 443-2265 or at [email protected] in advance of the application due date for further
instruction.
If you have any difficulties with the application, or have other questions or concerns, please
contact staff on (301) 443-2265 or at [email protected].

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INITIAL APPLICATION CHECKLIST
Please use the following checklist to ensure that your application is complete before sending it to
HHS. If HHS finds an application to be incomplete, HHS may deny the application.
____1. Provide a detailed response to Items 1-18 of the application
____2. Notify all appropriate units of local government and include copies of notices with
application
____3. Certify accuracy of application by signing Item 19 of the application
____4. Attach any requested documents, along with other documents the applicant feels will
present a more complete understanding of the proposed use of the property
____5. Certify applicant’s compliance with applicable Federal laws, insurance requirements, and
protection and maintenance standards of the property by signing Attachment A
____6. Complete and sign the Resolution to Acquire and Retransfer Property in Attachment B

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APPLICATION PART I FORMAT
Use the following format to complete your application. Include any supporting documentation
as attachments.
 At the top of the first page state the official name, address of the Federal installation
where the surplus property is located (include city, county, and State when giving
address), and GSA and/or landholding agency number assigned to the property.
 Put the GSA and/or landholding agency number assigned to the property at the top of
each additional page.
1.

Applicant Identification
State the legal name of the applicant organization and provide the applicant’s address,
phone number, and email address.

2.

Partner Identification
State the legal name of any other organization(s) that may participate in the operation of
the proposed homeless assistance program and provide its physical address, email
address, and phone number.
Note that the collaboration of multiple homeless service providers is permissible in order
to increase the services offered by the proposed program and to share in the operation and
maintenance of the property. However, the applicant organization must act as the lead
organization.

3.

Applicant Organizational Eligibility
A. State whether the applicant is a State, political subdivision of the State, or a private
nonprofit organization, tax-exempt under section 501(c)(3) of the Internal Revenue
Code of 1986, as amended, that provides homeless assistance. If the applicant is a
501(c)(3) tax-exempt nonprofit organization, attach a copy of the formal exemption
letter from the Internal Revenue Service as Exhibit 1 to the application.
B. Attach a copy of the document showing statutory or other authority which permits
your organization to acquire and hold title to real property for the proposed use. A
copy of the applicable citation from the Corporations Division of the Secretary of
State’s Office where the applicant is registered will satisfy this requirement. If the
applicant is a nonprofit corporation, present evidence showing said corporation’s
authorization, under its charter, to hold title to the real estate for which it has applied.
Provide a copy of the charter and State certification. Documents should be submitted
as Exhibit 2 to the application.

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4.

Partner Organizational Eligibility
Any partnering organizations must meet the same organizational eligibility requirements
as the applicant; accordingly, for each partnering organization, state whether the partner
is a State, political subdivision of the State, or a 501(c)(3) tax-exempt nonprofit
organization, that provides homeless assistance. For each partner that is a 501(c)(3) taxexempt nonprofit organization, attach a copy of its formal exemption letter from the
Internal Revenue Service as Exhibit 3 to the application.

5.

Authorized Representative
State the name and title of the official authorized to complete this transfer on behalf of
the applicant and provide that official’s physical address, email address, and phone
number. Please note that the authorized official must sign the application and be named
as the authorized official in the governing board resolution.

6.

Other Points of Contact
A. If the authorized official is not the representative to be contacted in day-to-day
matters relating to the completion and submittal of this application, please state the
name and title of the appropriate representative and provide that individual’s physical
address, email address, and phone number.
B. State the name and title of a representative for each partner and provide the
representative’s physical address, email address, and phone number.

7.

Applicant Accreditation and Licensure
State whether the applicant is accredited, approved, or licensed by a Federal or State
accrediting, approving, or licensing authority. If so, give the name of such authority and
provide a copy (as Exhibit 4) of any applicable documentation issued by the respective
authority.

8.

Partner Accreditation and Licensure
State whether any partnering organizations are accredited, approved, or licensed by a
Federal or State accrediting, approving, or licensing authority. If so, give the name of
such authority and provide a copy (as Exhibit 5) of any applicable documentation issued
by the respective authority.

9.

Partner Commitment
For each identified partner, provide an official commitment letter, memorandum of
agreement, or any other documentation detailing the planned cooperation with applicant.
This documentation should clearly indicate that each partner has demonstrated a
commitment and the capacity to provide the outlined support for the target population. If
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applicable, this should include partners expected to be either sources or recipients of
referrals for individuals/families to be served on the requested property. Submit as
Exhibit 6 of the application.
10.

Identification of the Requested Real Property
A.

B.

C.
D.

11.

Acquisition Type
A.

B.

12.

Provide a general description of the requested property, including information
related to the acreage, any improvements (buildings, structures, infrastructure,
etc.). For each building, provide the building number, name, and square footage.
The amount of property requested should not exceed normal operating
requirements. Note that a legal description is not required at this time, but HHS
may request such at a future date.
Identify the zoning and land use regulations applicable to the property. Also
identify any easements, including overhead and underground, which are reported
with the property, or are to be otherwise acquired for use in connection with the
property. If any such easements, rights of use, zoning regulations, or other
encumbrances, existing or proposed, would impede the homeless assistance
program, please identify. Describe how the applicant intends to resolve the stated
impediment.
State that the property is suitable for the proposed use. If not, explain.
Applicants may generally acquire related personal property included with the
available real property if the need and use are specifically included and justified
in the application. It is subject to the same discount allowance as the real property
for which you have applied. Identify such related personal property by an
inventory showing the description, serial number, or other adequate identification.
Applicants may obtain this information from the landholding and/or disposal
agency.

State whether applicant is requesting acquisition of the property by deed or lease.
If by lease, state the requested term, in years, of the initial lease. Note that unless
the applicant makes a showing of need that warrants a longer term, a lease term
will not exceed ten (10) years with an option to renew the lease for a successive
ten (10) years (i.e., no lease will exceed a total of 20 years).
If acquisition is by deed, the applicant must certify that it has consulted with all
State and local governmental entities with jurisdiction over the property and that
the proposed use will comply with all local zoning and use restrictions, including
local building code requirements.

Services Offered
Provide a narrative account of the proposed program to be implemented by the applicant
through the use of surplus Federal property. Your narrative should, at a minimum:

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A.

B.

C.
D.
13.

Identify the target population to whom the applicant will provide services.
Confirm, by statement, that the target population meets the definition of
“homeless” at 42 U.S.C. § 11302.
Identify and fully describe each service to be offered to program participants. The
description should identify the target population to be served (including any
information on whether the target populations for different services will vary),
whether participation is voluntary or mandatory, how often the service(s) will be
provided, who will provide the service(s), describe the service delivery model,
security measures, if any, and plans for overcoming any gaps in applicant’s
experience related to services currently provided and those proposed.
Describe any housing to be provided, as applicable.
Describe how the program will link housing and services, as applicable.

Implementation Plan
Provide a narrative description of the applicant’s program implementation plans. The
description should, at a minimum:
A.

B.

C.

D.

14.

Describe the time required for the completion of any improvements and for
bringing the property to full utilization. Note that an applicant must place the
property into its proposed use within 12 months from the date of transfer, or 36
months where new construction or major renovations are required.
Describe any anticipated improvements to the property (e.g. renovations or
construction), and plans for its conversion. Note that any future improvements or
renovations to the requested property planned for an unknown future date after the
property is in use, unless detailed in full including proposed plans and a cost
estimate in this application, are considered speculative at time of application and
must receive approval from HHS prior to commencing construction.
State that the renovation of existing buildings (if any), or construction of any new
buildings, will meet State and local building codes and/or regulations for the
proposed program of use.
Report the exact description of utilities required and state how arrangements will
be made for securing all needed utility services.

Need
A.
B.

C.

Define the proposed service area (city, county, or state).
Demonstrate that there is an unmet need for the proposed service(s) in the target
area/local community for the proposed target population(s). In so doing, the
applicant must provide a reasonable estimate of the number of homeless
individuals in the proposed service area and describe the basis for such estimate.
Note that if applicant proposes to serve a subset of the population, the estimate
should relate to that subset only.
Identify other facilities within the proposed service area that currently offer the
same type of service(s) applicant proposes to offer, and describe the services
provided and the number of clients each serves and/or provides beds for.
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D.

E.
F.

G.

H.

15.

Describe any gap between existing and needed services supported by the
information. Include any surveys, reports, or other documentation to support your
analysis, such as a municipality’s ten-year plan to end homelessness, Point-inTime counts, HMIS, other local reports or surveys on the number of persons
without shelter or without other needed supportive services, continuum of care
plans, etc. Data should be recent and not anecdotal. Include documentation as
Exhibit 7.
Provide an estimate of the number of clients to be served in a given year and
rationale for such estimate. If the number served is expected to vary greatly by
type of service offered, provide estimates for each major service offered.
If need stems from an emergency resulting from a disaster, explain fully.
If need is a result of requirements to comply with State standards, explain and
enclose, as Exhibit 8, certifications from appropriate State departments (i.e., State
statutes, court decisions, etc.).
Identify any real estate owned or leased by the applicant organization. If
applicable, include a statement that the real estate owned or leased by the
applicant organization is not suitable for the proposed program of utilization.
Demonstrate how applicant will fully utilize the requested property by providing a
rough floor plan (as Exhibit 9), including any existing improvements, the location
of the proposed services within the building, estimated square footage use of each
component of the proposed program; and location, type, size, and proposed use of
any new structures to be built on the property, as applicable.

Experience
Demonstrate that the applicant is qualified to implement the proposed program of use. At
a minimum:
A.

B.

C.
D.

Describe past experience and demonstrate success of the applicant relevant to the
proposed program, including its ability to operate and maintain real property. Be
specific, and include, at a minimum, the range of service(s) the applicant currently
provides and the length of time any current programs have been operating.
Describe program staff, including the number and qualifications of existing staff
that will implement the proposed program, and number and qualifications of staff
to be hired (if needed) to meet the demands of the newly proposed program. If
staff is to be hired, please describe positions to be filled and required
qualifications, intended hiring practices, and identify the pool from which the
applicant can draw.
To the extent that the services currently provided and the services proposed differ
in scope, describe how applicant plans to address that gap in experience.
Provide written recommendations, endorsements, and letters from appropriate
State agencies, public officials of State and local governments, and recognized
national or local sponsoring associations or organizations attesting to the
applicant’s past success and/or abilities to develop and/or operate programs such
as the one being proposed for serving the homeless. Only submit pertinent
information as Exhibit 10.
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16.

Local Government Notification
The applicant must notify the applicable unit of general local government responsible for
sewer, water, police, and fire services, in writing, of its proposed program. Submit a
copy of the written notifications as Exhibit 11 with the application.

17.

Completion of Attachments A and B
A.

B.

18.

The applicant must certify, by signature of Attachment A, its assurance of
compliance with nondiscrimination, insurance, and protection and maintenance
requirements.
Complete the governing board resolution, enclosed as Attachment B, authorizing
a representative to act on behalf of the applicant organization. Be sure to fill out
the information regarding the property name and description. Also note that the
certifying officer must be an official other than the representative named in the
Resolution.

Debarment, Suspension, Ineligibility, and Voluntary Exclusion Certification
The applicant certifies, by submission of this application, that neither it nor its principals
is presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in federal grant, award or public benefit
conveyance programs by any federal department or agency.
Failure to make required disclosures can result in adverse administrative action including
disapproval of applicant’s application, reversion of the property and any of the remedies
described in 45 CFR § 75.371, including suspension or debarment. (See also 2 CFR parts
180 and 376, and 31 U.S.C. 3321).
Where the applicant is unable to attest to the statements in this certification, it must state
such and include an explanation.
The applicant also certifies, by submission of this application, that neither it nor its
principals, have any federal liens or outstanding judgments against it. Where the
applicant is unable to certify this statement, it must state such and include an explanation.

19.

Certification

I, ______________________________________, on behalf of the applicant, am aware that
(Name of authorized official)

HHS relies on the accuracy of the statements contained in the application and material false
statements on the application may result in adverse administrative action and/or criminal
prosecution under 18 U.S.C. § 1001.
I, ______________________________________, certify that the information in the application
(Name of authorized official)

13

is true, accurate and complete to the best of my knowledge. I also understand that the
Department of Health and Human Services’ (HHS’) approval of the application does not
constitute the final decision on whether to transfer the property. Authority to assign the property
for transfer rests with the disposal agency, not HHS.
_______________________________________________________________
Name of Applicant
_______________________________________________________________
Signature and Title of Authorized Official
Date
_______________________________________________________________
Print Name of Authorized Official
If you have any questions regarding the application, or the application process, please call the Program Support
Center, Real Property Management Services, at (301)443-2265 or send an email to [email protected]. Applicants
can receive additional assistance if they have any problems with the application/transfer process by contacting the
National Law Center on Homelessness and Poverty at (202)638-2535. For general information on other homeless
assistance programs or grants, call the Interagency Council on Homelessness at (202)708-4663.

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ATTACHMENT A

Applicant Certification
1. The applicant will not discriminate on the basis of race, color, national origin, religion, sex, age,
familial status, or handicap in the use of the property, and will maintain the records required to
demonstrate compliance with the following Federal laws: section 606 of the Federal Property and
Administrative Services Act of 1949; the Fair Housing Act (42 U.S.C. § 3601-19); Executive
Order 11063 (Equal Opportunity in Housing), as applicable; Title VI of the Civil Rights Act of
1964 (42 U.S.C. § 2000d to d-4) (Nondiscrimination in Federally Assisted Programs); Title IX of
the Education Amendments of 1972 (20 U.S.C. § 1681); the prohibitions against discrimination
on the basis of age under the Age Discrimination Act of 1975 (42 U.S.C. § 6101-07) and
implementing regulations; and the prohibitions against otherwise qualified individuals with
handicaps under Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794); the
Architectural Barriers Act Accessibility Standards (ABAAS) (36 CFR 1191, Appendices C and
D); and all other implementing regulations for the above listed statutes.
2. The applicant agrees for itself, its successors and assigns, that it shall insure all conveyed
improvements against loss, damage, or destruction. If any such loss, damage, or destruction shall
occur during the period grantee holds title to said property subject to conditions subsequent 1
through 5, said insurance and all monies shall be held in trust by the grantee, its successors or
assigns, and shall be promptly used by the grantee for the purpose of repairing such
improvements and restoring the same to their former condition and use or for the purpose of
replacing said improvements with equivalent or more suitable improvements or, if not so used,
the grantee shall cause to be paid over to the Treasurer of the United States that part of the
insurance proceeds that is attributable to the Government's reversionary interest in the property
lost, damaged, or destroyed, determined on the basis of the fair market value of the facilities at
the time of the loss, damage, or destruction.
3. The applicant covenants and agrees for itself, its successors and assigns, that in the event the
grantor exercises its option to revert all right, title, and interest in the property to the grantor, or
the grantee voluntarily returns title to the property, the grantee shall provide protection to and
maintenance of the property until such time as the title reverts to and is accepted by the grantor.
Such protection and maintenance shall, at a minimum, conform to the standards prescribed by the
General Services Administration in its Customer Guidance for Real Property Disposal in effect as
of the date of the deed, as referred to in the Federal Management Regulations (FMR) §10275.965 (41 CFR 102-75.965). A copy of the applicable portions are attached (Attachment C) to
the application.

____________________________________________________________________
Name of Applicant

____________________________________________________________________
Signature and Title of Authorized Official
Date

____________________________________________________________________
Print Name of Authorized Official

15

ATTACHMENT B

Resolution to Acquire and Retransfer Property
Whereas, certain real property owned by the United States, located in the County of
______________________, State of ______________________, has been declared surplus and
is subject to assignment for disposal for homeless purposes by the Secretary of Health and
Human Services under the provisions of 40 U.S.C. §550, as amended, and Title V of the
McKinney-Vento Homeless Assistance Act, as amended; and the rules and regulations
promulgated pursuant thereto, more particularly described as follows [Please insert property
name and description below (full legal description is not required at this time)]:
Whereas, _____________________________________________________________________
(Legal name of applicant)

needs and can utilize said property for public health purposes in accordance with the
requirements of said Acts and the rules and regulations promulgated pursuant thereto, of which
____________________________’s governing Board or Directors or functional equivalent is
(Legal name of applicant)

fully informed, including commitments regarding use and time within which such use shall
commence.
Now, Therefore, Be It Resolved, that _______________________________________________
(Legal name of applicant)

has legal authority, is willing, and is in a position financially and otherwise to assume immediate
care and maintenance of the property, and that________________________________________,
(Name of Official(s) legally authorized)

_______________________________, is/are hereby authorized, for and on behalf of the
(Title of Official(s))

__________________________________________________________to do and perform any
(Legal name of applicant)

and all acts and things which may be necessary to carry out the foregoing resolution, including
the preparing, making, and filing of plans, applications, reports, and other documents; the
execution, acceptance, delivery, and recordation of agreements, deeds and other instruments
pertaining to the transfer of said property; and the payment of any and all sums necessary on
account of the purchase price thereof, including fees or costs incurred in connection with the
transfer of said property for surveys, title searches, appraisals, recordation of instruments, or
escrow costs, together with any payments by virtue of nonuse or deferral of use of the property.

16

If the applicant is unable to place the property into use with the time limitation indicated below
(or determines that a deferral of use should occur), it is understood that the
________________________________________________________ will, if directed to by the
(Legal name of the applicant)

Department of Health and Human Services or its successor in interest, pay to the Department
of Health and Human Services or its successor in interest for each month of nonuse beginning
twelve (12) months after the date of the deed, or thirty-six (36) months where construction or
major renovation is contemplated, the sum of 1/360 of the then fair market value for each month
of nonuse, in accordance with 45 C.F.R. Part 12.3(c), or retransfer the property as directed by the
Department of Health and Human Services or its successor in interest.
Be It Further Resolved and agreed that the Department of Health and Human Services or its
successor in interest is hereby authorized to retransfer the property in the event
______________________________________ ceases operations or abandons the property.
(Legal name of the applicant)

If the Department of Health and Human Services approves the application, the board will file a
copy of the application and standard deed/lease with their permanent minutes.

__________________________________________________________________
Legal Title of Governing Body of Applicant

__________________________________________________________________
Address

__________________________________________________________________
City
State
Zip Code

I, ___________________________________, hereby certify that I am the
(Name of Certifying Officer)

___________________________________, of the ____________________________________
(Title of Certifying Officer)

(Title of Governing Body)

and that the foregoing resolution is a true and correct copy of the resolution adopted by the vote
of a majority of members of ____________________________ present at a meeting of said
(Title of Governing Board)

Board on_____________ day ________________, 20____at which a quorum was present.

____________________________________
Signature of Certifying Officer
Note:

The person named in the Resolution cannot sign as the Certifying Officer.
17

ATTACHMENT C

Protection and Maintenance Standards
The following is an excerpt from the GSA’s Customer Guide to Real Property Disposal, as
referred to in the Federal Management Regulations (FMR) § 102-75.965 (41 CFR § 102-75.965):
Protection Standards
For all protected properties-• If a property is within the range of municipal or other public protection services but is outside
the geographic boundaries of the service provider, then advance arrangements should be made
with the local authorities to provide police and fire protection.
• If a property or facility has large areas that need protection, then use automobiles to patrol the
area.
• If a property is fenced, only keep open a minimum number of gates.
Fire protection or security personnel are not needed at-• Facilities that have no buildings, structures or related personal property.
• Facilities where the value of the improvements and/or related personal property (or realizable
recovery of their value) is less than the cost to protect and maintain the property for one year.
• Facilities with little value, which can be locked or boarded up and are located within public
police and fire department service areas.
• Facilities where major buildings do not contain large quantities of easily removable personal
property and also are equipped with automatic sprinklers supervised by a monitoring service.
• Facilities where agreements can be made with a lessee of a portion of the property to protect
the remaining portion(s) at no cost or nominal cost.
Properties that need a resident custodian (guard) are-• Facilities containing little removable personal property but have many buildings that will be
sold for off-site use when
- the buildings have low realizable value
- the buildings are spaced far enough apart that loss of more than a few buildings in a single
fire is improbable
- the buildings are located near water for firefighting purposes and the local public fire and
police protection services will respond promptly.
• Small inactive industrial and commercial facilities that need to remain open for inspection and
public fire and police protection can be secured by telephone.
• Facilities whose highest and best use is salvage.
• Facilities with only salvage value but are potentially dangerous and attractive to children or
curiosity seekers and posting signs is not sufficient to protect the public or the property.
Properties needing continuous guard service are-• Fenced facilities with high market value require one guard on duty at all times (5 guards in total
are required).
• These properties are permitted one open gate which can be locked during patrols.
• All buildings can be locked.
18

• Local fire and police protection can be secured by telephone.
Properties needing a high degree of protection
At a minimum, two firefighter-guards will be on duty at all times for the classes of facilities
listed below. Consider all relevant and pertinent factors when deciding on the number and
assignment of the guards.
• Facilities with a high market value that require an on-site fire-fighting force adequate to subdue
fires until outside help arrives.
• Facilities with a high market value without access to outside assistance require an on-site firefighting force adequate to extinguish fires.
• Facilities with a high market value with large areas to patrol.
• Facilities with a high market value with no fencing and containing large quantities of personal
property susceptible to pilferage.
• Facilities with a high market value needing several gates open for operating purposes.
Firefighter-Guards
Firefighters and guards provide fire protection and security for excess and surplus real property
requiring both forms of protection. Combine the duties of each to the maximum extent possible.
In the interest of cost savings, they can also be used for various miscellaneous services such as
grass/weed removal, servicing fire extinguishers and other activities related to the general
protection of the property.
Operating Requirements of Protection Units
Firefighter-guards or guards should periodically patrol facilities requiring protection. The
frequency of the patrols will be determined by the location and size of the facility, type of
structures and physical barriers, and the amount and type of activity at the facility. In some
instances, a centralized monitoring service provider will suffice.
Watchman’s Clock
To ensure adequate coverage of the entire property by firefighter-guards or guards, an approved
watchman’s clock should be provided, with key stations strategically located to enable guards to
cover the entire property.
Protection Alarm Equipment
Automatic fire detection devices and related equipment and services can substantially reduce
protection costs. However, using these devices are primarily for obtaining fire and police
protection in an emergency. Such devices can supplement or in some cases, eliminate the need
for guard patrols.
Sentry Dogs
Some high market value facilities that cover a large area and/or are in remote locations, invite
intrusion by curiosity seekers, hunters, vagrants, etc. These facilities require special protection
measures. Using sentry dogs is a cost effective alternative to additional security personnel. Get
advice on the use, care, and training from the nearest police department using sentry dogs. Also,
when sentry dogs are used to protect government property, post a sign with view unobstructed
that says "Warning—This Government Property Patrolled by Sentry Dogs."

19

Maintenance Standards
The following standards or criteria should be used as a guide for the upkeep of excess and
surplus real property:
Temporary Buildings and Structures
Vacant temporary structures should not be maintained except in unusual circumstances.
Temporary buildings housing personal property that cannot be readily removed to permanent
structures should be maintained only to the extent necessary to protect the personal property.
Permanent Buildings and Structures
(a) Don’t paint the interior. Only spot paint exterior wood or metal surfaces to prevent serious
deterioration.
(b) Limit carpentry and glazing to only that which is necessary to close openings to prevent
weather damage and pilferage, repair damage to floors, roofs, and side-walls to prevent
further damage, shoring and bracing to prevent structural damage, and other similar
operations.
(c) Patch damage to roofing and sheet metal as necessary.
(d) Perform masonry repairs, such as brick, tile, and concrete work only to prevent leakage or
disintegration or to protect against imminent structural damage.
(e) Don’t heat buildings for maintenance purposes except in unusual circumstances.
Mechanical and Electrical Installations
These include plumbing, heating, ventilating, air conditioning, sprinkler systems, fire alarm
systems, electrical equipment, elevators, and other similar systems.
For inactive facilities:
• Maintain mechanical and electrical systems only when necessary to stop or prevent serious
deterioration.
• Employ personnel for this work temporarily, at periodic intervals when an inspection indicates
that this work is necessary.
• De-energize electrical systems, drain water from all fixtures, turn off heat, and secure the
building against unauthorized entry.
• Drain sprinkler systems during freezing weather and reactivate when there is no danger of
freezing.
For active facilities:
• Keep equipment in reasonable operating condition.
• Operate equipment to service private tenants or procure utility services to distribute to private
tenants only to the extent necessary to comply with a lease or permit, or in cases where tenants
can’t get these services directly from utility companies or other sources.
• Inspect (periodically) facilities that have elevators and/or high-pressure boilers and related
equipment. Inspections should be made by qualified, licensed inspectors to protect against
injury or death to personnel and damage to property.
• Use individual heaters, when practical, instead of operating heating plants.
Grounds, Roads, Railroads, and Fencing

20

• Limit grounds maintenance to the removal of vegetation in order to avoid fire hazards and to
control poisonous or noxious plant growth in accordance with State and local laws and
regulations.
• Plow fire lanes where needed.
• Remove snow from roads and other areas to the extent necessary for access for maintenance,
fire protection, and other similar activities.
• Sell hay crops (wherever practicable) to the highest bidder (s) with the purchaser performing all
labor in connection with cutting and removal.
• Use agricultural and/or grazing leases to reduce costs of grounds maintenance, where practical.
• Maintain the portion of road network necessary for fire trucks and other minimum traffic.
These roads should be maintained to the extent necessary to allow safe passage at a reasonable
speed.
• Maintain railroads to the extent necessary for protection and maintenance operations or as
required in lease or permit provisions.
• Clear ditches and drainage facilities to allow surface water run-off.
• Fencing and other physical barriers should be sufficient to protect against unauthorized entry.
Utilities
In cases where utilities are purchased by contract, review the utility contracts to see if you can
save money by revising them.
For inactive properties:
• Maintain water systems, sewage disposal systems, electrical distribution systems, etc., to the
extent necessary to provide minimum service.
• De-energize electrical systems and turn off the water in buildings or areas that don’t require
these services.
• Don’t maintain utilities not in use or that service dismantled or abandoned buildings/structures.
For active properties:
• Operation rates for water supply, electrical power, and sewage disposal facilities should be far
below normal capacities.
• Use engineering studies to determine structural and operating changes necessary for maximum
economy.
• Turn off, rather than repair, leaky water lines unless they are necessary for fire protection or
other purposes.
Properties Disposed of as Salvage
Do not spend money to maintain property whose highest and best use is salvage.
Repairs
Limit repairs to additions or changes necessary for preservation and maintenance of the property
to-• Deter or prevent excessive, rapid, or dangerous deterioration or obsolescence.
• Restore property damaged by storm, flood, fire, accident, or earthquake when restoration is
required.

21

APPLICATION PART II
Should HHS determine that Part I of the application is approved, HHS will inform the applicant by
official letter. The letter will provide the applicant 45 days to complete and submit Part II of the
application. Responses to Part II of the application will assist HHS in making a determination on the
applicant’s financial ability to operate the proposed program and maintain the property.
As indicated in previous instructions, it is the applicant’s responsibility to ensure its application presents
all the information requested in a detailed, accurate, and complete manner. It is to the applicant’s benefit
to err on the side of providing too much information and documentation as opposed to omitting
information or not providing enough detail.
Please be aware that applicants may identify possible sources of Federal funding through the publication
Federal Programs to Help Homeless People (1993), produced by the Interagency Council on
Homelessness (ICH). You may obtain a copy by visiting the HUD User Web Store at
http://webstore.huduser.org/catalog/product_info.php/cPath/2/prodcuts_it/7548.
1. FINANCIAL ABILITY
A. Detail the estimated costs anticipated to prepare the property for full utilization, including:
1. Renovations to existing facilities;
2. Construction of new facilities; and
3. Changes to the land areas (e.g. parking, recreational, open space).
B. Provide an itemized list of estimated costs anticipated to operate the program, including any
maintenance costs. This should include such costs as initial start-up costs (i.e., furnishing and
equipment), salaries and benefits, utilities, security, program expenses, etc.
C. Give a full and complete statement of the ability to finance, operate, and maintain the
program and property requested. Identify the source of funding for converting the property
for its intended use, including any new improvements. Identify funding sources for program
operations separately. Be sure to include the capital outlay budget and the following, if
applicable: (Please also identify if there are any specific time limitations or restrictions in the
use of the funding.)
(1)
(2)
(3)
(4)

Special building funds;
Undistributed reserve;
Property tax rate;
Funds available for personnel and maintenance (include any expected volunteer
resources, if applicable);
(5) Amount raised by taxation;
(6) State appropriation;
(7) Rental Income; and
a. If any partnering organization will pay rent to the applicant organization, provide a
rental agreement (or draft agreement) detailing the terms of the rental amount. Note that
rent cannot exceed the cost of utilities and maintenance for the space used by the
organization paying rent.

22

b. Describe any rental agreements to be developed between the applicant and prospective
clients/residents (if applicable). Note that any rental agreement (and the description of
such an agreement in the application) must contain an assurance that rent will not exceed
30% of the client’s household income. Transferees must account for all rental income as
an identifiable item in their fiscal records and use the income for the approved program
from which it derived.
NOTE: HHS prohibits commercial income-producing activity (i.e. not rental income) on
transferred property, except in such cases where the income-producing activity’s goods
and/or services relate directly to the approved program. Any income produced must return to
the approved program in order to defray the costs of operation and maintenance and such
income must be identifiable in their fiscal records.
(8) Other (contracts, services, federal payments, fund-raisers, grants, etc.);
If the funding sources under “Other” are of a general nature, the application should provide
details for each source listed under “Other”, including the amount of funding, if it has been
awarded/received or the timeframe for application and award/receipt, details of award
including any restrictions/terms on use of funding, commitment letters, etc. If an applicant
has not secured the necessary funding, the applicant should describe its past success with
such funding sources, including such information as the type of grant(s) awarded and amount,
uses of past grants, prior fund-raising activities, etc.
(Please note that all submitted financial documentation must be no more than one-year old.)
D. If the applicant contemplates that major construction/renovation is necessary to make the
property suitable for full utilization, and funds are not currently available, give plans and
proposed sources of funding to carry out the proposed program and development. Please
include the estimated amount of funds each source will provide, including any anticipated
grants. Also, include a description of past success in obtaining funding and the likelihood of
obtaining future funding.

2.

COMPLETION OF ENVIRONMENTAL QUESTIONNAIRE
A.

The National Environmental Policy Act of 1969 (P.L. 91-190 42 U.S.C. Sections 43214347) requires consideration of the environmental effects that may result from major
Federal actions significantly affecting the quality of the human environment, including
real property conveyances. Your completion of the Environmental Questionnaire found
in Attachment D will assist us in evaluating any potential environmental effects arising
from your proposal. You are required to provide the documentation supporting your
questionnaire responses and may be required to provide more detailed information
at a later time.

23

Part II Certification
I, ______________________________________, on behalf of the applicant, am aware that
(Name of authorized official)
HHS relies on the accuracy of the statements contained in the application and material false statements on
the application may result in adverse administrative action and/or criminal prosecution under 18 U.S.C. §
1001.
I, ______________________________________, certify that the information in the application
(Name of authorized official)
is true, accurate and complete to the best of my knowledge. I also understand that the Department of
Health and Human Services’ (HHS’) approval of the application does not constitute the final decision on
whether to transfer the property. Authority to assign the property for transfer rests with the disposal
agency, not HHS.
_______________________________________________________________
Name of Applicant

_______________________________________________________________
Signature and Title of Authorized Official
Date
_______________________________________________________________
Print Name of Authorized Official
If you have any questions regarding the application, or the application process, please call the Program
Support Center, Real Property Management Services, at (301) 443-2265 or send an email to
[email protected]. Applicants can receive additional assistance if they have any problems with the
application/transfer process by contacting the National Law Center on Homelessness and Poverty at (202)
638-2535. For general information on other homeless assistance programs or grants, call the Interagency
Council on Homelessness at (202) 708-4663.

24

ATTACHMENT D

Environmental Questionnaire
Introduction
The Department of Health and Human Services (HHS) is required to include environmental
information in its decision-making activities, including the consideration of applications for the
use of excess and surplus real property for Homeless purposes under the Federal Real Property
Assistance Program. It is, therefore, necessary for the applicant to submit environmental
information to HHS. HHS uses this information to evaluate the potential environmental impacts
of your proposed program of use, as described in your application.
The General Services Administration (GSA) and other agencies (when appropriate) have
included environmental information in their management of the property, including the decision
to make it available for this program. However, the information provided does not include
information about your program’s use of the property including various actions and/or activities
which were unknown to the other agencies at the time of their disposal decisions.
This application is a request for HHS action (the transfer of Federal property). Therefore, HHS
retains the responsibility to evaluate independently the adequacy and accuracy of the information
submitted, and to make its own evaluation of the environmental issues which may arise.
HHS will use the requested information to determine if the requested action is a Categorical
Exclusion (CatEx) in accordance with the National Environmental Policy Act (NEPA) and its
implementing regulations. If the action is a CatEx, no further environmental review is required.
However, if there is insufficient information to make a determination, additional information will
be required. In some circumstances, such as the renovation of a Historic Property or major
construction, HHS may approve an incomplete application, subject to the completion of an
Environmental Assessment (EA) or an Environmental Impact Statement (EIS), if the application
is otherwise complete. If the applicant does not cooperate or refuses to provide requested
information for either an EA or an EIS, HHS will consider the application incomplete, and thus
disapproved.
Instructions
Please give a detailed response for each question. If a question is not applicable, state as such
along with any information that lead to that determination. Applicants must provide a basis for
determination for each answer and attach all relevant documents used to answer the questions.
Number and answer each question as presented, and include the applicant organization’s name
and the property’s name and location (municipality, and State) on the top of each page.
There is no need to duplicate any efforts made elsewhere. If an EA or an EIS has been
prepared on the proposed project for another local, state, or Federal agency which
addresses all of the requested information, attach the EA or EIS in lieu of attaching a
completed questionnaire.
Failure to provide the requested information will necessitate returning the application for
completion.

25

Basis for Determination and Documentation
The basis for determination and any requisite documentation must be traceable and establish the
factual data to support the response to each question. The information may include, but is not
limited to:
•
•
•

Printed Material: comprehensive land use plans, zoning maps, city master plans,
environmental baseline surveys, an EA/EIS, other documented Federal determinations,
etc.;
Personal Contacts: communication with accepted authorities on the subject(s) along with
supporting documentation, including the name, organization, the title of the person
contacted and the date of the conversation; and,
Site Visit: initial inspection of the property, and surrounding area, in order to make
preliminary determinations regarding environmental issues, along with supporting
documentation including the date of the site visit, by whom, and observations; testing or
sampling not required at this time.

Guidance
 The requested information will assist HHS in the environmental review of the proposed
Federal action – transferring the property to the applicant organization. Detailed and
clearly stated responses allow HHS to more efficiently and accurately assess the
environmental impact, and are in the applicant organization’s best interest.
 Several questions ask to compare the proposed use to the prior use. If the property is
currently a vacant structure, use the last occupied use of the structure as the point of
comparison. If the structure has been vacant for an extended period of time, or is an
undeveloped tract of land, use its current unoccupied state as the point of reference.
 The questions focus on the impact of the proposed use of property on the surrounding
environment or the demands of the program on public resources. To better answer these
questions, keep in mind the demographics of the area and the demographics of the
clientele, including age, served by the proposed program. For example, if the
surrounding area is industrial or undeveloped, a temporary shelter for homeless youth
will have a different demographic than the surrounding area and most likely require
different and/or additional public resources.
 Due diligence is expected. It is not necessary to consult an environmental professional,
but applicants should research any unknowns, contact local and State officials for
information, and request any available information from the landholding Federal agency,
GSA, and/or the U.S. Department of Housing and Urban Development (HUD).
 Applicants may contact the disposal agency to arrange a site visit.
 Please be sure that any information obtained is current and relevant. If a document is
lengthy or otherwise difficult to attach to the application, provide a citation for the
document so that an outside reviewer can locate the specific reference, e.g., author,
document title, publication date, and page number.
 Applicants should contact HHS if they encounter any difficulty or confusion in trying to
find requested information. Applicants may reach a Realty Specialist at (301) 443-2265
or at [email protected].

26

Questions
CURRENT CONDITION OF PROPERTY
1. If there are any structures on the property:
a. List the year in which they were built.
b. If the structure is over fifty (50) years-old:
i. Is the structure on the National Register of Historic Places?
ii. Contact the State Historic Preservation Officer (SHPO) to determine if the
proposed use will adversely impact a historic property. Document and
provide a copy of any response from the SHPO.
2. Describe any current contamination or adverse environmental condition of the requested
property and the ground water below the property. This includes lead-based paint and
asbestos in any current structures on the property. Applicants should also list any
publicly known contamination on neighboring sites, including if there are any sites on the
U.S. Environmental Protection Agency’s National Priorities List (NPL) within 1 mile of
the property (available at http://www.epa.gov/superfund/sites/npl/npl.htm). An in-depth
search is not required.
3. State any known institutional controls on the property due to environmental
contamination (this may include use restrictions, covenants, deed notices, etc. imposed by
a prior owner or local, State, or Federal agency).
4. Provide copies of any relevant land use plans (Federal, state, or local) for the requested
property, and explain any known conflict(s) between the proposed use and any relevant
land use plans, including zoning.
WASTE AND POLLUTION
5. What kind/amount of waste will the proposed program create (e.g. municipal waste,
construction debris, hazardous waste)?
a. If there will be any hazardous waste produced/disposed of on the property, please
detail which activities will produce the waste. Such activities include, but are not
limited to, dry cleaning, air conditioning repair and service, motor pools,
automobile repair, welding, services stations, gas stations, landscaping,
agricultural and farming activities, print shops, hospitals, clinics, and medical
facilities.
b. Detail the disposal plans for any hazardous waste.
6. What pollution prevention measures, if any, does the applicant plan for the location,
design, construction, or operation of the proposed use (including soil, sedimentation, or
erosion controls, and source reduction/recycling)?

27

7. Does your State or local government require a storm water control plan for the proposed
use of the property?
SURROUNDING COMMUNITY
8. What is the scope of the use of the surrounding property (e.g. residential, commercial, or
mixed-use), and is the proposed use uncharacteristic of the area?
9. Will there be any change in the community noise level, relevant to the time of day, due to
the proposed use of the property?
10. Describe any direct or indirect effect on nearby parkland, other public lands, or areas of
recognized or scenic value.
11. Will the proposed use of the property emit, or cause to be emitted, any air pollutants?
12. Will the proposed use of the property change the amount of carbon dioxide and other
greenhouse gases released as compared to the prior use of the property?
PUBLIC RESOURCES
13. Does the proposed program require the construction/development of any new public
facilities or services (e.g. schools, medical facilities, roads, sewage, or public
transportation)?
14. Will the proposed use of the property require an increase in or the generation of more
energy/electricity? (Contact the local utility or supplier and document the name and date
of contact.)
15. Will the proposed use of the property require an increase in other non-electric utilities
such as natural gas?
16. Will the proposed use of the property change the amount of solid waste generated on the
property compared to the prior use?
17. Will the proposed use of the property increase the amount of wastewater in need of
treatment from the property compared to the prior use?
FEDERAL LAW
18. Safe Drinking Water:
a. Is the property in proximity to an EPA designated sole source aquifer?
b. Will the proposed use of the property change the amount of drinking water
needed as compared to the prior use?

28

19. Floodplains:
a. Is the property located in a floodplain?
b. Will the proposed use of the property encourage development in a floodplain?
20. Wetlands and Navigable Waters (lakes, rivers, streams, etc.; including any ditch, culvert,
or other source of water that has a hydrologic connection to a larger body of water):
a. Are there any wetlands or water resources on or near the property?
b. Does the proposed use of the property require construction in wetlands?
c. If construction is required, will there be any dredging or filling of a wetland or
water resource?
21. Coastal Zone Management:
a. Will the proposed use of the property directly affect a designated Coastal Zone?
(Coastal Zones are not necessarily the just area immediately next to the coast;
some zones encompass the entire State, such as Florida, or major watersheds such
as the Chesapeake Bay watershed.)
b. If so, provide the State Coastal Zone Management Plan and highlight any
potential conflicts? (Each State adjacent to a coast, including those located in the
Great Lakes region, should have a State office to manage its coastal zone
development and use.)
22. Wild and Scenic Rivers:
a. Is the property located near a wild, scenic, or recreational river area?
b. If so, will the proposed use create conditions inconsistent with the character of the
river?
23. Farmland Protection:
a. Will the proposed use of the property convert any agricultural lands to nonagricultural uses?
24. Wilderness:
a. Is the property located near a designated Wilderness Area or other public land
with a similar designation?
b. If so, will the proposed program have any direct or indirect effect on the
Wilderness Area or public land?
25. Endangered Species:
a. Does the property have, or is it located near, any critical habitat of an endangered
or threatened species?
b. Will the proposed use of the property affect, directly or indirectly, any Federal or
State listed endangered or threatened species?
DUE DILIGENCE
26. Demonstrate that the applicant has performed due diligence to ensure that the proposed
use of the property will not result in a known violation of applicable (Federal, State, or

29

local) laws or regulations that protect the environment or public health and safety. If the
proposed use will result in a known violation, explain fully.
27. Describe, within reason, any known controversy over the environmental effects of the
proposed use for the property.
CERTIFICATION
28. Either complete a copy of the below certification or complete and remove this page from
the application.

I, ______________________________________, certify that the information in the
(Name of Authorized Official)

Environmental Questionnaire is true, correct, and accurate to the best of my knowledge.
I understand that HHS may require more environmental information prior to either the
approval/disapproval of the application or transfer of the requested property. Such information
may include, but is not limited to, Environmental Assessments or Environmental Impact
Statements.

_______________________________________________________________
Name of Applicant

_______________________________________________________________
Signature and Title of Authorized Official
Date

_______________________________________________________________
Print Name of Authorized Official

30