SF429B and Cover-V1.0 (1).pdf

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SF-429 Real Property Status Report (Cover Page)

Information Analysis, Inc.

D:20061211100100- 05'00'

D:20061211100100- 05'00'

REAL PROPERTY STATUS REPORT SF-429

(COVER PAGE)

OMB Number: 4040-0016

Expiration Date: 02/28/2022

1. Federal Agency and Organizational Element to Which Report is Submitted:

4a. UEI:

Recipient Organization Name:

Street1:

Street2:

City:

State:

ZIP / Postal Code:

Country:

County:

Province:

2. Federal Grant(s) or Other Identifying Number(s) Assigned by Federal Agency(ies):

3. Recipient Organization (name and complete address including zip code):

4b. EIN:

5. Recipient Account or Identifying Number:

7. Report End Date:(MM/DD/YYYY)

First Name:

Middle Name:

Last Name:

Suffix:

Prefix:

6. Contact Person for this Report:

Phone:

Email:

Fax:

8. Real Property Status Report – Attachments: [check the applicable block(s)]:

9. Comments:

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 Official:

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:

11b. Signature of Authorized Certifying Official:

11c. Telephone (area code, number, extension):

11d. Email Address:

11e. Date Report Submitted (MM/DD/YYYY):

12. Agency use only

Mandatory:

Report End Date: Enter the end date of the period for which the report is submitted as mm/dd/yyyy. This block only applies when completing Attachment A.:

Federal Grant or Other Identifying Number: Enter the related Federal grant, cooperative agreement or other Federal financial assistance award instrument number(s), or other identifying number(s) assigned to the Federal financial assistance award. This field is required.:

UEI: Enter the recipient organization’s Unique Entity Identifier (UEI). This field is required.:

Organization Name: Enter the Recipient Organization Name. This field is required.:

Street 1: Enter the first line of the Street Address. This field is required.:

Street 2: Enter the second line of the Street Address.:

City: Enter the City. This field is required.:

County: Enter the County.:

State: Select the state, US possession or military code from the provided list.:

Province: Enter the Province. :

Country: Select the Country from the provided list. This field is required.: USA: UNITED STATES

Zip / Postal Code: Enter the Postal Code (e.g., ZIP code). :

EIN: Enter the recipient organization’s Employer Identification Number (EIN) as assigned by the Internal Revenue Service. This field is required.:

Federal Agency and Organizational Element: Enter the name of the Federal agency and the agency organization element identified in the award document or as otherwise instructed by the agency. This field is required.:

Recipient Account Number or Identifying Number: Enter the account number or any other identifying number assigned by the recipient to the award. This field is required.:

Prefix: Select the Prefix from the provided list or enter a new Prefix not provided on the list.:

First Name: Enter the First Name. This field is required.:

Middle Name: Enter the Middle Name.:

Last Name: Enter the Last Name. This field is required.:

Suffix: Select the Suffix from the provided list or enter a new Suffix not provided on the list.:

Phone: Enter the Phone Number. This field is required.:

Email: Enter a valid Email Address. This field is required.:

Fax: Enter the Fax Number.:

Attachment C (Disposition Request): Check to select.:

Attachment B (Request to Acquire, Improve or Furnish): Check to select.:

Attachment A (General Reporting): Check to select.:

FileName:

MimeType:

href:

hashAlgorithm:

HashValue_data:

Comments: Provide any special notes or comments regarding the real property being reported or the report itself.:

Comments - Add Attachment:

Provide any special notes or comments regarding the real property being reported or the report itself.:

Comments - Delete Attachment:

Comments - View Attachment:

Title: Enter the title of the authorized certifying official. This field is required.:

Signature: The authorized certifying official must sign here certifying to the facts presented in the report. This field is required.:

Telephone: Enter the telephone number (including area code and extension) of the individual listed in section 11a. This field is required.:

Email: Enter a valid Email Address. This field is required.:

Date Report Submitted: Enter the date the report is submitted to the Federal agency as mm/dd/yyyy. This field is required.:

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RR_SF424 Page 1 mhughes

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D:20061211100100- 05'00'

Real Property Status Report

ATTACHMENT B

(Request to Acquire, Improve or Furnish) SF-429-B

OMB Number: 4040-0016

Expiration Date: 02/28/2022

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. Description of Real Property:

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

Street1:

Street2:

City:

State:

ZIP / Postal Code:

Country:

County:

Province:

Zoning Information:

GPS Location Longitude:

GPS Location Latitude:

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

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

14c. Proposed Acquisition Date (MM/DD/YYYY):

14d. Land Acreage or Square Units:

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

Enter Amount:

Select units:

Enter Amounts:

Gross

Usable

Select units:

14f. Appraised Value (Valuation):

Federal Share:

Share Percentage %:

Non-Federal Share:

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

14g. Are there any Uniform Relocation Act (URA) requirements applicable to this real property?

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

If yes, describe them:

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?

If yes, describe them:

14j. Does the proposed action employ green/sustainable practices (check all that apply)?

14k. What was the cumulative energy consumption for the facility in the past 12 months?:

A. Electric (kWh) or (Btu)

B. Petroleum (Gal)

C. Natural Gas (cu ft)

D. Other

(Specify)

14l. What is the anticipated cumulative energy use for the 12 months following completion of the proposed acquisition/construction/renovation project?

A. Electric (kWh) or (Btu)

B. Petroleum (Gal)

C. Natural Gas (cu ft)

D. Other

(Specify)

15. Remarks:

Mandatory:

Federal Grant or Other Identifying Number: Enter Federal Grant or Other Identifying Number Assigned by Federal Agency. This field is required.:

Description of Real Property: Enter Description.:

dataEntered:

Street1: Enter the first line of the Street Address. :

Street2: Enter the second line of the Street Address.:

City: Enter the City. :

County: Enter the County.:

State: Select the state, US possession or military code from the provided list.:

Province: Enter the Province. :

Country: Select the Country from the provided list. :

Zip / Postal Code: Enter the Postal Code (e.g., ZIP code). :

Zoning Information: Enter the Zoning Information.:

GPS Location Longitude: Enter the GPS Location Longitude.:

GPS Location Latitude: Enter the GPS Location Latitude.:

Intended Use: Describe the intended use of the real property and how it will benefit the program.:

Real Property Ownership Type(s) - A. Owned: Check to select.:

Real Property Ownership Type(s) - D. Corporate: Check to select.:

Real Property Ownership Type(s) - B. Co-Owned: Check to select.:

Real Property Ownership Type(s) - E. Joint Tenancy: Check to select.:

Real Property Ownership Type(s) - C. Fee Simple: Check to select.:

Real Property Ownership Type(s) - F. Partnership: Check to select.:

Real Property Ownership Type(s) - G. Limited Liability Partnership: Check to select.:

Real Property Ownership Type(s) - H. Co-Operative: Check to select.:

Real Property Ownership Type(s) - I. Government Furnished Property: Check to select.:

Real Property Ownership Type(s) - J. Other (Describe): Check to select.:

Description: If "other" is selected, enter text to explain.:

Proposed Acquisition Date: Enter the Date as mm/dd/yyyy. :

Amount: Enter Land Acreage or Square Units.:

Units: Select one.

Square Meters: Check to select.:

Gross: Enter the Gross Amount.:

Usable: Enter the Usable Amount.:

Units: Select one.

Square Feet: Check to select.:

Federal Share: Enter the Federal Share.:

Share Percentage: Enter the Federal Share Percentage.:

Non-Federal Share: Enter the Non-Federal Share.:

Share Percentage: Enter the Non-Federal Share Percentage.:

Total (sum of Federal and Non-Federal Share): This is a calculated field.:

Total (sum of Federal and Non-Federal Share) Percentage: This is a calculated field.:

Are there any Uniform Relocation Act (URA) requirements applicable to this real property? - No: Check to select.:

Are there any environmental compliance requirements related to the real property? - No: Check to select.:

FileName:

MimeType:

href:

hashAlgorithm:

HashValue_data:

Environmental Compliance Requirements:

If Yes, attach description.:

Environmental Compliance Requirements - Add Attachment:

If Yes, attach description.:

Environmental Compliance Requirements - Delete Attachment:

Environmental Compliance Requirements - View Attachment:

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? - No: Check to select.:

NHPA Description:

If Yes, attach description.:

NHPA Description - Add Attachment:

If Yes, attach description.:

NHPA Description - Delete Attachment:

NHPA Description - View Attachment:

A. Integrated Design Principles: Check to select.:

B. Enhances Indoor Environmental Quality: Check to select.:

C. Protects and Conserves Water (anticipated water reduction): Check to select.:

D. Reduces Environmental Impact of Materials: Check to select.:

E. Optimizes Energy Performance (anticipated energy reduction): Check to select.:

A. Electric (kWh): Enter the anticipated cumulative energy use for the 12 months following completion of the proposed acquisition/construction/renovation project.:

or Btu: Enter the anticipated cumulative energy use for the 12 months following completion of the proposed acquisition/construction/renovation project.:

B. Petroleum (Gal): Enter the anticipated cumulative energy use for the 12 months following completion of the proposed acquisition/construction/renovation project.:

C. Natural Gas (cu ft): Enter the anticipated cumulative energy use for the 12 months following completion of the proposed acquisition/construction/renovation project.:

D. Other: Enter the anticipated cumulative energy use for the 12 months following completion of the proposed acquisition/construction/renovation project.:

Other Specify: Specify, if Other.:

Remarks: Attach remarks.:

Remarks - Add Attachment:

Attach remarks.:

Remarks - Delete Attachment:

Remarks - View Attachment: