Form 4040-0016 SF-429-B Real Property Status Report ATTACHMENT B (Reque

Real Property Status Report
ATTACHMENT B
(Request to Acquire, Improve or Furnish) SF-429-B

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

Federal Grant or Other Identifying Number Assigned
by Federal Agency (#2 on cover page)
Complete the applicable blocks below for each parcel of real property for which you are requesting to acquire, Improve, or furnish (duplicate
this page to provide information for each parcel of real property under the Federal financial assistance award identified in section 2):

13a. Descrip1ion of Real Property:

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13b. Address of Real Property (legal description and complete address including zoning information):
Street1:
Street2:
City:
State:
Country:

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Zoning Information:

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County:

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GPS Location Longitude:

GPS Location Latitude:

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ZIP / Postal Code:

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- ·- --

-

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Province:

-

..

14a. Describe the intended use of the real property and how it will benefit the program:

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14b. Proposed Real Property Ownership Type(s):

DA. Owned

□
□

E. Joint Tenancy

D B. Co-Owned oc. Fee Simple
D F, Partnership D G, Limited Liability Partnership

I. Government Furnished Properly

D J. Other (Describe):

14c. Proposed Acquisition Date (MMIDDIYYYY):
14d. Land Acreage or Square Units:
Enter Amount:
Select units:

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D Acres

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D Square Kilometers

141. Appraised Value (Valuation):
Federal Share:
Non-Federal Share:

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□
□

D . Corporate
H. Co-Operative

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

D Square Feet

□

Gross

Square Meters

Select units:

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j

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D Square Feet D Square Meters

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SI
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14g. Are there any Uniform Relocation Act (URA) requirements applicable to this real property?
14h. Arc there any environmental compliance requirements related to lhe real property?

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Usable

Share Percentage %:

$

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

If yes. describe them:

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II

Add Aaachm;,ru

□

D Yes

D Yes

□

□

No

No

II

Delete Att"chmcnt

11

Delete Attachm<'nl

II

v,ew At1r1chnien

II

v,ew Atlaci,mcnt

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14i. In accordance with the National Historic Preservation Act (NHPA), does the property possess historic significance. and/or is it listed or eligible
for listing in the National Register of Historic Places?
Yes
No
If yes. describe them:

D

I

II

Add Aliachrnenl

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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 4040-0016. The time required to complete this information collection is estimated to average 1 hour 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