Real Property Status Report (Cover Page)
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13REAL PROPERTY STATUS REPORT
(COVER PAGE)
Page:
of :
Pages
1. Federal Agency and Organizational Element to Which
2. Federal Grant(s) or Other Identifying Number(s) Assigned by
Report is Submitted:
Federal Agency(ies):
3. Recipient Organization (Name and complete address including zip code):
4a. DUNS Number:
4b. EIN:
5. Recipient Account or Identifying
6. Contact Person for this Report:
Number:
Name:
Phone:
Email:
Fax:
7. Report End Date:
(MM/DD/YYYY)
8. Real Property Status Report – Attachments: [check the applicable block(s)]:
___ : Attachment A (General Reporting) attached
___ : Attachment B (Request to Acquire, Improve or Furnish) attached
___ : Attachment C (Disposition Request) attached
9. Comments (attach additional sheets if necessary):
10. Certification: I certify to the best of my knowledge and belief that all information presented in this report is true, correct
and complete and constitutes a material representation of fact upon which the Federal government may rely.
11a. Typed or Printed Name and Title of Authorized Certifying
11c. Telephone (area code, number, extension):
Official:
11d. Email Address:
11b. Signature of Authorized Certifying Official:
11e. Date Report Submitted (MM/DD/YYYY):
12. Agency use only
i
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