Real Property Status Report (Cover Page) (Page 2 of 13) in pdf

[ATTACHMENT A]

(General Reporting)

Federal Grant or Other Identifying Number Assigned by Federal Agency (#2 on cover page)

Page:

of:

Pages

Complete the applicable blocks below for each parcel of real property being reported (duplicate this page to

provide information for each parcel of real property being reported under the Federal financial assistance

award identified in section 2):

13. Period of Federal Interest (MM/DD/YYYY): From:

To:

14a. Description of Real Property:

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

14c. Acreage:

14d. Gross Square Meters and Usable Square Meters (i.e., of

building, house, etc.):

14e. Real Property Ownership Type:

___ A. Owned ___ B. Co-Owned ___ C. Fee Simple

___ D. Corporate ___ E. Joint Tenancy ___ F. Partnership ___ G. Limited Liability Partnership ___ H. Co-Operative

___ I. Other (Describe):___________________________________________________

14f. Beginning date of Federal Interest (MM/DD/YYYY):

___ Acquisition ___ Renovation ___ Construction

Government Furnished Property

14g. Real Property Cost:

Share Percentage %:

Federal Share:

[

Non-Federal Share:

[

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

[

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

___ Yes ___ No ___ NA

If yes, describe the instrument used and enter the date and jurisdiction in which it was recorded:

14i. Has Federally required insurance coverage been secured for this real property? ___ Yes ___ No

(See instructions for more details)

14j. Are there any Uniform Relocation Act requirements applicable to this real property? ___ Yes ___ No

14k. Are there any environmental compliance requirements related to the real property? ___ Yes ___ No

If yes, describe them (Attach additional sheets if necessary):

14l. In accordance with the National Historic Preservation Act (NHPA), does the property possess historic significance, and/or is listed

or eligible for listing in the National Register of Historic Places? ___ Yes ___ No

If yes, describe them (Attach additional sheets if necessary):

15. Has a significant change occurred with the real property that is not otherwise captured above? ___ Yes ___ No

If yes, describe the change (Attach additional sheets if necessary):

16. Real Property Disposition Status:

___ A. Sold ___ B. Transferred to different award ___ C. Used in other Federally sponsored project/program

___ D. Transferred title ___ E. Retained Title

i. If the Federal agency provided the recipient disposition instructions to sell or retain title to the real property, enter the amount of

funds owed to the Federal government:

ii. If applicable, enter the amount of any net proceeds from the sale of the real property and describe how the proceeds were

distributed:

iii. If the Federal agency directed the recipient to transfer title to the real property, enter the amount of funds the Federal Agency

owes:

Real Property Status Report (Cover Page) Page 2

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