Real Property Status Report (Cover Page) Page 3


17. Remarks (attach additional sheets if necessary):
(Request to Acquire, Improve or Furnish)
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 to be furnished real property (duplicate this page to provide information for each parcel of real
property under the Federal financial assistance award identified in section 2):
13a. Description of Real Property:
13b. Address of Real Property (legal description and complete address including zoning information):
14a. Describe the intended use of the real property and how it will benefit the program (attach additional sheets if necessary):
14b. Proposed 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):______________________________________________________
14c. Proposed Acquisition Date (MM/DD/YYYY):
14d. Acreage:
14e. Gross Square Meters and Usable Square Meters (i.e., of
building, house, etc.):
14f. Appraised Value (Valuation):
Share Percentage %:
Federal Share:
Non-Federal Share:
Total (sum of Federal and Non-Federal Share):
14g. Are there any Uniform Relocation Act requirements applicable to this real property? ___ Yes ___ No
14h. Are there any environmental compliance requirements related to the real property? ___ Yes ___ No
If yes, describe them (Attach additional sheets if necessary):
14i. 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. Remarks (attach additional sheets if necessary):


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