Form 10-168e HPCA SHPO Review & Recommendation Sheet Rehabilitation -

NPS Form 10-168e (Rev. 8/2023)
National Park Service
OMB Control No. 1024-0009

HISTORIC PRESERVATION CERTIFICATION APPLICATION
STATE HISTORIC PRESERVATION OFFICE
REVIEW & RECOMMENDATION SHEET
PART 2 / PART 3—REHABILITATION
SECTION 1. APPLICATION INFORMATION

PROJECT NUMBER

Historic Property Name
Property Address
Certified Historic Structure (select one)

☐

☐ Pending

Part 2

☐
☐
☐

☐ Yes

Preliminary consultation (date)

.

Applying for state tax credit

☐

.

Completed rehabilitation work conforms to work previously
approved
Completed rehabilitation work differs substantively from work
previously approved (describe divergences from Part 2 scope
of work in Section 5)

☐

Part 3 (Part 2 not previously reviewed)

☐
☐

Amendment (applicant signature date
Request for an advisory determination for a phase

.

Additional information requested (date/s)

Part 3 (Part 2 previously reviewed)

☐

.

Application received (date)

.

Complete information received (date)
Transmitted to NPS (date)

☐

Property visited by SHPO staff (date/s):
before

)

, during

and/or after

☐

.

,

rehabilitation.

Applicant informed of SHPO recommendation

SECTION 2. APPLICATION MATERIALS

☐ Photographs ☐ Other (list)
.
☐ Photographs (PDF) ☐ Photographs (up to 20 individual in folder)

Sent previously:
Attachments:

☐ Plans

☐ Other (list) ____________

Documentation remaining on file in SHPO (e.g., masonry repointing samples, specifications)

.

SECTION 3. SHPO RECOMMENDATION
______________, who meets the Secretary of the Interior’s Professional Qualification Standards, has reviewed this application.
Include names of any additional staff to be copied on NPS decisions ____________________________________

This rehabilitation work (select only one):

☐
☐
☐
☐
☐

meets the Standards.

☐

warrants denial for lack of information.

☐

is being forwarded without recommendation.

meets the Standards with concerns.
meets the Standards only if the attached conditions are met (Part 2 and Amendments only).
does not meet Standard number(s)

and for the reasons described in Section 5.

does not meet Standard number(s)
as completed, but could be brought into conformance with the
Standards if the remedial work recommended in Section 5 is completed (Part 3 only).

Date

State Historic Preservation Office Signature
This is a review sheet only and does not constitute an official certification of rehabilitation.

SECTION 4. ISSUES

☐

Alteration, removal, or covering of significant interior features or
finishes

☐
☐

Changes in significant interior plan, spaces, or circulation patterns

☐

Alteration of significant exterior features or surfaces

☐
☐

Window replacement

☐

Extensive site work, adjacent new construction, or demolition of adjacent structures

Additions, including rooftop

Other (explain)

.

SECTION 5. SHPO EVALUATION
Explain the recommendation and any concerns, particularly issues checked in Section 4. Where denial is recommended, explain fully.
For Part 3s, describe any work that differs substantially from the approved work. For Part 3s that do not meet the Standards as
completed, describe remedial work, if any, that could enable the project to meet the Standards. Comment on notable aspects of the
project, such as technical design innovations or creative solutions.

SECTION 6. NATIONAL PARK SERVICE EVALUATION

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

HISTORIC PRESERVATION CERTIFICATION APPLICATION
NATIONAL PARK SERVICE
CONDITIONS

Historic Property Name

Project Number

Property Address

The rehabilitation of this property as described in the Historic Preservation Certification Application will meet the Secretary
of the Interior’s Standards for Rehabilitation provided that the following condition(s) is/are met:

Photographs documenting that the conditions have been met must be submitted with the Request for Certification of Completed
Work.
Any substantive change in the work as described in the application should be brought to the attention of the State Historic
Preservation Office and the National Park Service in writing, using the Amendment/Advisory Determination form, prior to execution to
ensure that the proposed project continues to meet the Standards.

Date

State Historic Preservation Office Signature

The National Park Service has determined that this project will meet the Secretary of the Interior Standards for
Rehabilitation if the condition(s) listed above are met.

Date

National Park Service Signature

HISTORIC PRESERVATION CERTIFICTION APPLICATION
STATE HISTORIC PRESERVATION OFFICE
REVIEW & RECOMMENDATION SHEET
PART 2 / 3 – 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 information may prevent or impede you from receiving consideration for
the requested benefit.
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 4 hours per response when completed in association with NPS Form
10-168a (Part 2); 2 hours per response when completed in association with NPS Form 10-168b (Amendment / Advisory Determination);
and 3.5 hours per response when completed in association with NPS Form 10-168c (Part 3), 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, 13461 Sunrise Valley Drive, Mail Stop 244, Reston, VA
20191 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))

THIS PAGE DOES NOT NEED TO BE PRINTED OR SUMBITTED TO NPS