Form 10-900 National Register of Historic Places Registration Form

NPS Form 10-900 (Rev. 06/2018)

OMB Control No. 1024-0018

National Park Service

NATIONAL REGISTER OF HISTORIC PLACES REGISTRATION FORM

This form is for use in nominating or requesting determinations for individual properties and
districts. See instructions in National Register Bulletin, How to Complete the National Register of
Historic Places Registration Form. If any item does not apply to the property being documented,
enter "N/A" for "not applicable." For functions, architectural classification, materials, and areas of
significance, enter only categories and subcategories from the instructions.
1. Name of Property
Historic name:
Other names/site number:
Name of related multiple property listing: (Enter "N/A" if property is not part of a multiple
property listing

2. Location
Street & number:
City or town:

State:

 Not for publication:

County:

 Vicinity:

3. State/Federal Agency Certification
As the designated authority under the National Historic Preservation Act, as amended,
I hereby certify that this  nomination  request for determination of eligibility meets the
documentation standards for registering properties in the National Register of Historic
Places and meets the procedural and professional requirements set forth in 36 CFR Part 60.
In my opinion, the property  meets  does not meet the National Register Criteria. I
recommend that this property be considered significant at the following level(s) of
significance:

 National

 Statewide

 Local

Applicable National Register Criteria:

A

B

C

D

Signature of commenting official Title:

Date

State or Federal agency/bureau or Tribal Government

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NPS Form 10-900 (Rev. 06/2018)
National Park Service

OMB Control No. 1024-0018

Name of Property

In my opinion, the property

County and State

meets

does not meet the National Register criteria.

Signature of commenting official Title:

Date

State or Federal agency/bureau or Tribal Government
National Park Service Certification
I hereby certify that this property is:
 entered in the National Register
 determined eligible for the National Register
 determined not eligible for the National Register
 removed from the National Register
 other (explain:) _____________________

______________________________________________________________________
Signature of the Keeper
Date of Action
4. Classification
Ownership of Property (Check as many boxes as apply.)
 Private:
 Public – Local
 Public – State
 Public – Federal
Category of Property (Check only one box.)
 Building(s)
 District
 Site
 Structure
 Object

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NPS Form 10-900 (Rev. 06/2018)
National Park Service

OMB Control No. 1024-0018

Name of Property

Number of Resources within Property
(Do not include previously listed resources in the count)
Contributing
Noncontributing
_____________
_____________

County and State

buildings

_____________

_____________

sites

_____________

_____________

structures

_____________

_____________

objects

_____________

______________

Total

Number of contributing resources previously listed in the National Register _________
5. Function or Use
Historic Functions
(Enter categories from instructions.)

Current Functions
(Enter categories from instructions.)

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NPS Form 10-900 (Rev. 06/2018)
National Park Service

OMB Control No. 1024-0018

Name of Property

County and State

6. Description
Architectural Classification
(Enter categories from instructions.)

Materials: (enter categories from instructions.)
Principal exterior materials of the property: ________________________

Narrative Description
(Describe the historic and current physical appearance and condition of the property. Describe
contributing and noncontributing resources if applicable. Begin with a summary paragraph that
briefly describes the general characteristics of the property, such as its location, type, style,
method of construction, setting, size, and significant features. Indicate whether the property has
historic integrity.)
Summary Paragraph

Narrative Description

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NPS Form 10-900 (Rev. 06/2018)
National Park Service

OMB Control No. 1024-0018

Name of Property

County and State

7. Statement of Significance

Applicable National Register Criteria
(Mark "x" in one or more boxes for the criteria qualifying the property for National Register
listing.)




A. Property is associated with events that have made a significant contribution to the
broad patterns of our history
B. Property is associated with the lives of persons significant in our past.



C. Property embodies the distinctive characteristics of a type, period, or method of
construction or represents the work of a master, or possesses high artistic values, or
represents a significant and distinguishable entity whose components lack individual
distinction.



D. Property has yielded, or is likely to yield, information important in prehistory or history.

Criteria Considerations (Mark “x” in all the boxes that apply.)
A. Owned by a religious institution or used for religious purposes
B. Removed from its original location
C. A birthplace or grave
D. A cemetery
E. A reconstructed building, object, or structure
F. A commemorative property
G. Less than 50 years old or achieving significance within the past 50 years









Areas of Significance
(Enter categories from instructions.)

Period of Significance

Significant Dates

Significant Person
(Complete only if Criterion B is marked above.)

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NPS Form 10-900 (Rev. 06/2018)
National Park Service

OMB Control No. 1024-0018

Name of Property

County and State

Cultural Affiliation

Architect/Builder

Statement of Significance Summary Paragraph (Provide a summary paragraph that includes
level of significance, applicable criteria, justification for the period of significance, and any
applicable criteria considerations.)

Narrative Statement of Significance (Provide at least one paragraph for each area of
significance.)

8. Major Bibliographical References
Bibliography (Cite the books, articles, and other sources used in preparing this form.)

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NPS Form 10-900 (Rev. 06/2018)
National Park Service

OMB Control No. 1024-0018

Name of Property

County and State

Previous documentation on file (NPS):

 preliminary determination of individual listing (36 CFR 67) has been requested
 previously listed in the National Register
 previously determined eligible by the National Register
 designated a National Historic Landmark
 recorded by Historic American Buildings Survey #____________
 recorded by Historic American Engineering Record # __________
 recorded by Historic American Landscape Survey # ___________
Primary location of additional data:
 State Historic Preservation Office
 Other State agency
 Federal agency
 Local government
 University
 Other
Name of repository: _____________________________________
Historic Resources Survey Number (if assigned): ________________
9. Geographical Data
Acreage of Property _______________

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NPS Form 10-900 (Rev. 06/2018)
National Park Service

OMB Control No. 1024-0018

Name of Property

County and State

Use either the UTM system or latitude/longitude coordinates
Latitude/Longitude Coordinates (decimal degrees)
Datum if other than WGS84: __________
(enter coordinates to 6 decimal places)
1. Latitude:
Longitude:
2. Latitude:

Longitude:

3. Latitude:

Longitude:

4. Latitude:

Longitude:

Or
UTM References
Datum (indicated on USGS map):

 NAD 1927

or

 NAD 1983

1. Zone:

Easting:

Northing:

2. Zone:

Easting:

Northing:

3. Zone:

Easting:

Northing:

4. Zone:

Easting:

Northing:

Verbal Boundary Description (Describe the boundaries of the property.)

Boundary Justification (Explain why the boundaries were selected.)

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NPS Form 10-900 (Rev. 06/2018)
National Park Service

OMB Control No. 1024-0018

Name of Property

County and State

10. Form Prepared By
Name/Title:
Organization:
Street & Number:
City or Town:
State:
Zip Code:
e-mail
Telephone:
Date
Additional Documentation
Submit the following items with the completed form:
•

Maps: A USGS map or equivalent (7.5- or 15-minute series) indicating the property's
location.

•

Sketch map for historic districts and properties having large acreage or numerous
resources. Key all photographs to this map.

•

Additional items: (Check with the SHPO, TPO, or FPO for any additional items.)

Photographs
Submit clear and descriptive photographs. The size of each image must be 1600x1200
pixels (minimum), 3000x2000 preferred, at 300 ppi (pixels per inch) or larger. Key all
photographs to the sketch map. Each photograph must be numbered, and that number must
correspond to the photograph number on the photo log. For simplicity, the name of the
photographer, photo date, etc. may be listed once on the photograph log and doesn’t need
to be labeled on every photograph.

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NPS Form 10-900 (Rev. 06/2018)
National Park Service

OMB Control No. 1024-0018

Name of Property

County and State

Photo Log
Name of Property:
City or Vicinity:
County:

State:

Photographer:
Date Photographed:
Description of Photograph(s) and number, include description of view indicating direction of
camera:

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NPS Form 10-900 (Rev. 06/2018)
National Park Service

Name of Property

OMB Control No. 1024-0018

NOTICES

County and State

Privacy Act
Statement
Authority: This inf ormation collection is authorized by the National Historic Preservation Act, as
amended (16 U.S.C.460 et seq.), and 36 CFR 60 and 63.
Purposes and Uses: This inf ormation is being collected f or nominations to the National Register
of Historic Places to nominate properties f or listing or determine eligibility f or listing, to list properties,
and to amend existing listings.
Ef f ects of Nondisclosure: Voluntary, however, response to this request is required to obtain a benef it
in accordance with the National Historic Preservation Act, as amended (16 U.S.C.460 et seq.).
Paperwork Reduction Act Statement
The Paperwork Reduction Act requires us to tell you why we are collecting this inf ormation,
how we will use it, and whether or not you have to respond. Pursuant to National Historic
Preservation Act, as amended (16 U.S.C.460 et seq.), and 36 CFR 60 and 63, this inf ormation is
collected f rom applicants nominating properties to the National Register of Historic Places f or
listing or determine eligibility f or listing, to list properties, and to amend existing listings. to provide
the necessary f acts to enable the Secretary of the Interior to evaluate the applicant's eligibility f or
inclusion in the National Register of Historic Places. A f ederal agency may not conduct or
sponsor, and a person is not required to respond to, a collection of inf ormation unless it displays a
valid OMB control number. OMB has approved this collection of inf ormation and assigned
Control No. 1024-0018.
Estimated Burden
Statement
Public reporting burden f or this f orm is estimated to average 250 hours per response including time f or
reviewing instructions, gathering and maintaining data, and completing and reviewing the f orm. Send
comments regarding this burden estimate or any other aspect of this collection of inf ormation, including
suggestions f or reducing this burden, to the Inf ormation Collection Clearance Of f icer, National Park
Service, 12201 Sunrise Valley Drive Reston, Virginia 20192. Do not send your completed f orm to this
address.

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