Form 10 168 – Fill Out and Use This PDF

		UNITED STATES DEPARTMENT OF THE INTERIOR		OMB Approved
		NATIONAL PARK SERVICE		No. 1024-0009
				Form 10-168
		HISTORIC PRESERVATION CERTIFICATION APPLICATION		Rev. 2014
		AMENDMENT / ADVISORY DETERMINATION
			NPS Project Number
Instructions: This page must bear the applicant's original signature and must be dated.
1. Property name
Property address

Summarize information here; continue on following page if necessary.

3.Project Contact (if different from applicant)

Name							Company
Street					City					State
Zip			Telephone		Email Address

4. Applicant

I hereby attest that the information I have provided is, to the best of my knowledge, correct. I further attest that [check one or both boxes, as applicable] (1)		I am the
owner of the above-described property within the meaning of "owner" set forth in 36 CFR § 67.2 (2011), and/or (2)	if I am not the fee simple owner of the above-

described property, 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 (i) either is attached to this application form and incorporated herein, or has been previously submitted, and (ii) meets the requirements of 36 CFR § 67.3(a)(1) (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.

Name

Signature

Date

Applicant Entity

SSN

or TIN

Street

City

State

Zip

Telephone

Email Address

Applicant, SSN, or TIN has changed since previously submitted application.

NPS Official Use Only

The National Park Service has reviewed this amendment to the Historic Preservation Certification Application and has determined that the amendment:

meets the Secretary of the Interior’s Standards for Rehabilitation.

will meet the Secretary of the Interior’s Standard for Rehabilitation if the attached conditions are met.

does not meet the Secretary of the Interior’s Standards for Rehabilitation.

updates the information on file and does not affect the certification.

Advisory Determinations:

The National Park Service has determined that the work completed in this phase is consistent with the Secretary of the Interior’s Standards for Rehabilitation. This determination is advisory only. A formal certification of rehabilitation can be issued only after all rehabilitation work and any associated site work or new construction have been completed. This approval could be superseded if it is found that the overall rehabilitation does not meet the Secretary’s Standards. A copy of this form will be provided to the Internal Revenue Service.

Date	National Park Service Authorized Signature

NPS conditions or comments attached

HISTORIC PRESERVATION CERTIFICATION APPLICATION

AMENDMENT / ADVISORY DETERMINATION

Property name

NPS Project Number

Property address

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