Form 4040-0016 SF-429-C Real Property Status Report ATTACHMENT C (Dispo

Real Property Status Report
ATTACHMENT C
(Disposition or Encumbrance Request) SF-429-C

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

Federal Grant or Other ldenlilying Number Assigned
by Federal Agency (#2 on cover pago)

Complete the applicable blocks below for each parcel of real property for which you arc seeking disposition or other Instructions (duplicate
this page to provide Information for each parcel of real property under the Federal financial assistance award Identified in section 2). If a
section does not apply, enter "N/A":
13a. Description of Real Property:

I

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

Street2:

I

City:

State:

Country:

Zoning Information:

I

GPS Location Longitude:

I

13c. Land Acreage or Square Unils:
Enter Amounl:

Select units:

I

I

0 Acres

I

D Square Kilometers

□
□

GPS Location Latitude:

Enter Amounts:
Gross

Square Feet

Square Meiers

B. Transfer to different award

D D. Transfer title D E. Retain Title

□

I

Province:

I

ZIP / Postal Code:

I

I

I
I

I
I

I

13d. Gross and Usable Square Footage/Meters (i.e., of building, house. etc.):
Select units:

□

I

I

□

D Square Feet

,ff''

14a. Disposition Preference or Encumbrance Request [Clieck one]:

□

I

County:

I

,.

0 A. Sell

I
I

Usable

I

I

Square Meiers

-

C. Use in other Federally sponsored project/program

F. Encumber Property

14b. If this is a request to transfer Federal lnlorest lo a different award, specify the proposed grant number and funding agency:
Grant Number:

I

I

Funding Agency:

I

14c. If lhis is a request to use the real property in other Federal-sponsored projects/activities, describe the proposed use of the real property:

I

II

Add Attachment

14d. If this is a request to transfer title. identify the proposed receiving entity:
14e. Appraised Value (Valuation):
Federal Share:

Non-Federal Share:

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

II

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I

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I
I

II

Add Aaadm1em

I

I

I

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!CJ%]

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14g. Are there any environmental compliance requirements related to the real property?

I

II

'\� ....

Share Percentage %:

s
$1
$1
$1

14f. Are there any Uniform Relocation Act (URA) requirements applicable to this real property?
If yes, describe tllem:

I

D Yes

D Yes

□

No

□

No

11 Oele1t Att;1chrnent II

V11,w /�tt.�chmf,n\

I

11 Delete AaacLm , 1 11

,c-,•; Attnd;mcr,t

I

14h. 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

D

AFile Typeapplication/pdfFile Modified2018-10-12File Created2018-10-12