Form 10-168c HPCA Part 3 - Request for Certification of Completed Wor

NPS Form 10-168c (Rev. 6/2023)
National Park Service
OMB Control No. 1024-0009

HISTORIC PRESERVATION CERTIFICATION APPLICATION
PART 3 – REQUEST FOR CERTIFICATION OF COMPLETED WORK

NPS Project Number

Instructions: This page must bear the applicant's original signature and must be dated.

1.

Historic Property Name
Street
City

County

Is property a certified historic structure?

2.

Yes

If yes, date of NPS certification

Project Data
Project completed and building placed in service date

Estimated rehabilitation costs (QRE)

Total estimated costs (QRE plus non-QRE)
/

Number of low-moderate housing units before/after rehabilitation

/

Project Contact (if different from applicant)
Name

Company

Street
Zip

4.

Zip

OR date of National Register listing

Project start date

Number of housing units before/after rehabilitation

3.

No

State

City
Telephone

State

Email Address

Applicant (List all additional owners on next page.)
I hereby attest that the information I have provided is, to the best of my knowledge, correct and that I am the owner of the above-described property within the meaning
of "owner" set forth in 36 CFR § 67.2 (2011). For purposes of this attestation, the singular shall include the plural wherever appropriate. I understand that knowing and
willful falsification of factual representations in this application may subject me to fines and imprisonment under 18 U.S.C. § 1001, which, under certain circumstances,
provides for imprisonment of up to 8 years. Additionally:
If I am not the fee simple owner of the above described property, I have checked this box to attest that the fee simple owner is aware of the action I am taking
relative to this application and has no objection, as noted in a written statement from the owner, a copy of which statement (a) either is attached to this application
form and incorporated herein,or has been previously submitted, and (b) meets the requirements of 36 CFR § 67.3(a)(1) (2011).
Applicant, SSN, or TIN has changed since previously submitted application.
There are no additional owners within the meaning of "owner" set forth in 36 CFR § 67.2 (2011).
Name
Applicant Entity

SSN

Street
Zip

Date

Signature

City
Telephone

or TIN
State

Email Address

NPS Official Use Only
The National Park Service has reviewed the Historic Preservation Certification Application – Request for Certification of Completed Work (Part 3) for this property and has determined that:
the completed rehabilitation meets the Secretary of the Interior’s Standards for Rehabilitation and is consistent with the historic character of the property and, where
applicable, the district in which it is located. Effective the date indicated below, the rehabilitation of the “certified historic structure” is hereby designated a “certified
rehabilitation.” This certification is to be used in conjunction with appropriate Internal Revenue Service regulations. Questions concerning specific tax consequences or
interpretations of the Internal Revenue Code should be addressed to the Internal Revenue Service. Completed projects may be inspected by an authorized representative
of the Secretary to determine if the work meets the Standards for Rehabilitation. The Secretary reserves the right to make inspections at any time up to five years after
completion of the rehabilitation and to revoke certification, if it is determined that the rehabilitation project was not undertaken as presented by the owner in the application
form and supporting documentation, or the owner, upon obtaining certification, undertook unapproved further alterations as part of the rehabilitation project inconsistent
with the Secretary’s Standards for Rehabilitation.
the completed rehabilitation meets the Secretary of the Interior’s Standards for Rehabilitation. However, because this property is not yet a “certified historic structure,” the
rehabilitation cannot be designated a “certified rehabilitation” eligible for Federal tax credits at this time. The property will become a “certified historic structure” on the date
it or the historic district in which it is located is listed in the National Register of Historic Places. On that date, the completed rehabilitation will automatically become a
“certified rehabilitation.” It is the owner’s responsibility to obtain such listing through the State Historic Preservation Office. Questions concerning specific tax
consequences or interpretations of the Internal Revenue Code should be addressed to the Internal Revenue Service. Completed projects may be inspected by an
authorized representative of the Secretary to determine if the work meets the Standards for Rehabilitation. The Secretary reserves the right to make inspections at any
time up to five years after completion of the rehabilitation and to revoke certification, if it is determined that the rehabilitation project was not undertaken as presented by
the owner in the application form and supporting documentation, or the owner, upon obtaining certification, undertook unapproved further alterations as part of the
rehabilitation project inconsistent with the Secretary’s Standards for Rehabilitation.
the rehabilitation is not consistent with the historic character of the property or the district in which it is located and that the project does not meet the Secretary of the
Interior’s Standards for Rehabilitation.
A copy of this determination will be provided to the Internal Revenue Service in accordance with Federal law.

Date

National Park Service Authorized Signature
NPS Comments Attached

HISTORIC PRESERVATION CERTIFICATION APPLICATION
PART 3 – REQUEST FOR CERTIFICATION OF COMPLETED WORK

Historic Property Name

NPS Project Number

Property Address

Additional Owners. Continue on additional sheets as needed to list all owners.

Name

SSN

or TIN

Street Address
City

Name

State

SSN

Zip

or TIN

Street Address
City

Name

State

SSN

Zip

or TIN

Street Address
City

Name

State

SSN

Zip

or TIN

Street Address
City

Name

State

SSN

Zip

or TIN

Street Address
City

Name

State

SSN

Zip

or TIN

Street Address
City

Name

State

SSN

Zip

or TIN

Street Address
City

Name

State

SSN

Zip

or TIN

Street Address
City

State

Zip

Page 1 of 1

HISTORIC PRESERVATION CERTIFICTION APPLICATION
PART 3 – REQUEST FOR CERTIFICATION OF COMPLETED REHABILITATION
NOTICES
Privacy Act Statement
Authority: 26 U.S. Code § 47 - Rehabilitation credit; 26 U.S. Code § 170 - Charitable, etc., contributions and gifts.
Purpose: To enable the Secretary of the Interior to evaluate the historic significance of structures and whether the
rehabilitation of such structures preserves their historic character. The primary use of this information by the
Secretary of the Interior will be to certify to the Secretary of the Treasury that the applicant is eligible for Federal tax
incentives for historic preservation. This application is used by the Internal Revenue Service to confirm that applicants
for the tax incentives have obtained the certification concerning historic structures and historic rehabilitations that are
required by law.
Routine uses: The information will be used by the National Park Service and the State Historic Preservation Offices
and disclosed to the Internal Revenue Service to determine if the applicant is eligible for Federal tax incentives.
Disclosure: Voluntary, however, failure to provide the requested informationmay prevent or impede you from
receiving consideration for the requested benefit.
Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b):
Your Social Security Number (SSN) is needed to identify records unique to you. Applicants are required to provide
their social security or taxpayer identification number for activities subject to collection of fees and charges by the
National Park Service. Failure to disclose your SSN may prevent or delay the processing of your application. The
authority for soliciting your SSN is 31 U.S.C. 7701. The information gathered through the use of the SSN will be used
only as necessary for processing this application and collecting and reporting any delinquent financial obligations.
Use of the SSN will be carried out in accordance with established regulations and published notices of system of
records.
Paperwork Reduction Act Statement
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) through the State Historic
Preservation Officer in order to enable the Secretary of the Interior to gain the benefit of the State review of
applications for Federal tax incentives for historic preservation by owners of historic properties. Information collected
on this form, including names and all written comments, is subject to disclosure. All applicable parts of the form must
be completed in order to receive consideration for the requested benefit. A Federal agency may not conduct or
sponsor, and a person is not required to respond a collection of information unless it displays a currently valid OMB
control number. OMB has approved this collection and assigned it control number 1024-0009.
Estimated Burden Statement
Public reporting burden for this form is estimated to average 14 hours per response including the time it takes to
read, gather and maintain data, review instructions and complete the form. Direct comments regarding these burden
estimates, or any aspects of this form, to the Information Collection Clearance Officer, National Park Service, 12201
Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192. Please do not send your form to this address.
Records Retention Statement
Permanent. Transfer all permanent records to NARA 15 years after closure. (NPS Records Schedule, Resource
Management and Lands (Item 1.A.2) (N1-79-08-1))

FOR APPLICANT RECORDS ONLY – THIS PAGE DOES NOT NEED TO BE PRINTED FOR APPLICATION