Form 4040-0016 SF-429-A Real Property Status Report ATTACHMENT A (Gener

0MB Number: 4040-0016
Expiration Date: mm/dd/yyyy

Real Property Status Report
ATTACHMENT A (General Reporting) SF-429-A
Federal Grant or Other Identifying Number Assigned
by Federal Agency (#2 on cover page)

Complete the applicable b locks below for each parcel of real propert� being reporte � (du_p!ica!e this _Page '.o provide information for each
parce1 of reaI property being reported under the Federal financial assistance award 1dcnt1f1ed in section 2).

0 Acquisition O Renovation

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From:I

13. Period and type of Federal Interest (MM/OO/YYYY):

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To: I

0 Government Furnished Property

O Construction

14a. Description or Real Property:

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14b. Address of Real Property (legal description and complete address including zoning information):
Stroet1:

Street2:

City:

State:

Country:

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Zoning Information:

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14c. Land Acreage or Square Units:
Select units:

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GPS Location Latitude:

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Province:

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0 Acres
D Square Feet
0 Square Kilometers D Square Meters

0 A. Owned

E. Joint Tenancy

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141. Real Property Cost:
Federal Share:

D

Gross

Select units:

J. Other (Describe):

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0 Square Feet D Square Meters

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□

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$1

Total (sum of Fodera/ and Non-Federal Share):$

Usable

0. Corporate

H. Co-Operative

Share Percentage %:

$
$1

Non-Federal Share:

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Enter Amounts:

D B. Co-Owned 0 C. Fee Simple
0 F. Partnership 0 G. Limited Liability Partnership

I. Government Furnished Property

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14d. Gross and Usable Square Footage/Meters (i.e., of building, house, etc.):

14e. Real Property Ownership Type(s):

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□

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ZIP I Postal Code:

GPS Location Longitude:

Enter Amount:

County:

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1[:==)%1
IC=:]%1
IC=:]%1

14g. Has a deed. lien. covenant. or other related documentation been recorded to establish Federal interest in this real property?

D

Yes

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No

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N/A

If yes (unless previously reported), describe the instrument used and enter the date and jurisdiction in which it was recorded:

Date:

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I Jurisdiction: I

14h. Has Federally required insurance coverage been secured for this real property?
See instructions for more details.

0 Yes

14i. Are there any Uniform Relocation Act (URA) requirements applicable to this real property?
14j. Are there any environmental compliance requirements related to the real property?
If yes, describe them:

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11

j(1

1t2cnm..,1,.

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D Yes

No

0Yes

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No

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11 Cc:le'e ,-.,acr;n� 111 II

No

"e,•, AHat:.t,me 1

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