Sf 429 Form – Fill Out and Use This PDF

					OMB Control No.: 3090-0296
					Expires: 07/31/2014
		REAL PROPERTY STATUS REPORT SF-429
			(COVER PAGE)
					Page:	of :	Pages
1. Federal Agency and Organizational Element to Which			2. Federal Grant(s) or Other Identifying Number(s) Assigned by
Report is Submitted:			Federal Agency(ies):
3. Recipient Organization (name and complete address including zip code):
4a. DUNS Number:	4b. EIN:	5. Recipient Account or Identifying		6. Contact Person for this Report:
		Number:		Name:
				Phone:
				Email:
				Fax:
7. Report End Date:
(MM/DD/YYYY)
8. Real Property Status Report – Attachments: [check the applicable block(s)]:
___ : Attachment A (General Reporting) attached
___ : Attachment B (Request to Acquire, Improve or Furnish) attached
___ : Attachment C (Disposition Request) attached
9. Comments (attach additional sheets if necessary):

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	11c. Telephone (area code, number, extension):
Official:
		11d.	Email Address:
11b.	Signature of Authorized Certifying Official:	11e.	Date Report Submitted (MM/DD/YYYY):
		12. Agency use only

	OMB Control No.: 3090-0296
	Expires: 07/31/2014
Real Property Status Report
ATTACHMENT A (General Reporting) SF-429-A
Federal Grant or Other Identifying Number Assigned by Federal Agency (#2 on cover page)		Page:		of: Pages

Complete the applicable blocks below for each parcel of real property being reported (duplicate this page to provide information for each parcel of real property being reported under the Federal financial assistance award identified in section 2):

13.	Period and type of Federal Interest (MM/DD/YYYY): From:				To:
___	Acquisition	___ Renovation	___ Construction		Government Furnished Property
14a.	Description of Real Property:

14b. Address of Real Property (legal description and complete address including zoning information):

14c. Land Acreage or Square Units:		14d. Gross and Usable Square Footage/Meters (i.e., of building, house,
Enter Amount:________________		etc.):
Select units: __Acres	__Square Feet	Enter Amounts: Gross ___________ Usable ___________
__Square Kilometers	__ Square Meters	Select Units: __Square Feet __Square Meters

14e. Real Property Ownership Type(s):
___ A. Owned	___ B. Co-Owned	___ C. Fee Simple
___ D. Corporate	___ E. Joint Tenancy		___ F. Partnership	___ G. Limited Liability Partnership		___ H. Co-Operative
___ I. Government Furnished Property		___ J. Other (Describe):___________________________________________________
14f. Real Property Cost:			$	Share Percentage %:
Federal Share:			$	[	%]
Non-Federal Share:			$	[	%]
Total (sum of Federal and Non-Federal Share):			$	[	%]

14g. Has a deed, lien, covenant, or other related documentation been recorded to establish Federal interest in this real property?

___ Yes ___ No ___ N/A

If yes (unless previously reported), describe the instrument used and enter the date and jurisdiction in which it was recorded:

14h. Has Federally required insurance coverage been secured for this real property? ___ Yes		___ No
See instructions for more details.
14i.	Are there any Uniform Relocation Act (URA) requirements applicable to this real property? ___ Yes		___ No
14j.	Are there any environmental compliance requirements related to the real property? ___ Yes	___ No

If yes, describe them (attach additional sheets if necessary):

14k. 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? ___ Yes	___ No
If yes, describe them (attach additional sheets if necessary):

15.Has a significant change occurred with the real property, or is there an anticipated change expected during the next reporting period? ___

Yes	___ No
If yes, describe the change (attach additional sheets if necessary):
16. Real Property Disposition Status:
___ A. Sold		___ B. Transferred to different award		___ C. Used in other Federally sponsored project/program
___ D. Transferred title			___ E. Retained Title	___ F. N/A

i. If the Federal agency provided the recipient disposition instructions to sell or retain title to the real property, enter the amount of funds owed to the Federal government:

ii. If applicable, enter the amount of any net proceeds from the sale of the real property and describe how the proceeds were distributed:

iii. If the Federal agency directed the recipient to transfer title to the real property, enter the amount of funds the Federal Agency owes:

17. Indicate the cumulative energy consumption for the previous 12 months:

A. Electric (kWh)______ or (Btu) _________ B. Petroleum (Gal)_______C. Natural Gas (cu ft) ________D. Other (Specify)_______

18. Remarks (attach additional sheets if necessary):

Attachment A (General Reporting) to Real Property Status Report SF-429

OMB Control No.: 3090-0296

Expires: 07/31/2014

Real Property Status Report

ATTACHMENT B

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

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):

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(s):
___ A. Owned	___ B. Co-Owned		___ C. Fee Simple
___ D. Corporate	___ E. Joint Tenancy			___ F. Partnership	___ G. Limited Liability Partnership		___ H. Co-Operative
___ I. Government Furnished Property			___ J. Other (Describe):______________________________________________________
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,
Enter Amount:________________						etc.):
Select units: __Acres		__Square Feet				Enter Amounts: Gross ___________ Usable ___________
__Square Kilometers		__ Square Meters				Select Units: __Square Feet	__Square Meters

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 (URA) 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 it listed or eligible for

listing in the National Register of Historic Places? ___ Yes	___ No
If yes, describe them (attach additional sheets if necessary):

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

A. ___ Integrated Design Principles?

B. ___Enhances Indoor Environmental Quality?

C. ___Protects and Conserves Water (anticipated water reduction)? D. ___Reduces Environmental Impact of Materials?

E.___Optimizes Energy Performance (anticipated energy reduction)?

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 (attach additional sheets if necessary):

Attachment B (Request to Acquire, Improve or Furnish) to Real Property Status Report SF-429

OMB Control No.: 3090-0296

Expires: 07/31/2014

Real Property Status Report

ATTACHMENT C

(Disposition or Encumbrance Request) SF-429-C

Complete the applicable blocks below for each parcel of real property for which you are seeking disposition or other instructions (duplicate this page to provide information for each parcel of real property under the Federal financial assistance award identified in section 2). If a section does not apply, enter “N/A”:

13a. Description of Real Property:

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

14a. Disposition Preference or Encumbrance Request [Check one]:

___A. Sell		___B. Transfer to different award			___C. Use in other Federally sponsored project/program
	D. Transfer title		___E. Retain Title	___F.	Encumber Property

14b. If this is a request to transfer Federal Interest to a different award, specify the proposed grant number and funding agency:

14c. If this is a request to use the real property in other Federal-sponsored projects/activities, describe the proposed use of the real property:

14d. If this is a request to transfer title, identify the proposed receiving entity:

14e. Appraised Value:	$	Share Percentage %:
Federal Share:	$	[	%]
Non-Federal Share:	$	[	%]
Total (sum of Federal and Non-Federal Share):	$	[	%]
14f. Are there any Uniform Relocation Act (URA) requirements applicable to this real property? ___ Yes				___ No
14g. Are there any environmental compliance requirements related to the real property? ___ Yes			___ No
If yes, describe them (attach additional sheets if necessary):

14h. 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? ___ Yes	___ No
If yes, describe them (attach additional sheets if necessary):

14i. If this is a request to encumber the property, identify the party or parties to whom the property is proposed to be encumbered and attach related information (See instructions for more details):

15.If this is a request for a release from the obligation to report on the real property, describe the reasons for the request (attach additional sheets if necessary):

16.Remarks (attach additional sheets if necessary):

Attachment C (Disposition or Encumbrance Request) to Real Property Status Report SF-429

OMB Control No.: 3090-0296

Expires: 07/31/2014

INSTRUCTIONS FOR THE SF-429 Real Property Status Report

Public reporting burden for this collection of information is estimated to average 240 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.

This is a standard report to be used by recipients of Federal financial assistance to report real property status (Attachment A) or to request agency instructions on real property (Attachments B, C) that was/will be provided as Government Furnished Property (GFP) or acquired (i.e., purchased or constructed) in whole or in part under a Federal financial assistance award (i.e., grant, cooperative agreement, etc.). This includes real property that was improved using Federal funds and real property that was donated to a Federal project in the form of a match or

cost share donation. This report is to be used for awards that establish a Federal Interest on real property. The instructions below address each section of the Real Property Status Report. This report should be used

to report on or request instructions for single/individual and/or multiple parcels of real property (land, buildings, etc.). The report elements are contained in Attachment A and the request elements are contained in Attachments B and C.

A.Instructions Related to Cover Page follows:

1.Federal Agency and Organizational Element to Which Report is Submitted. Enter the name of the Federal agency and the agency organization element identified in the award document or as otherwise instructed by the agency.

2.Federal Grant(s) or Other Identifying Number(s) Assigned by Federal Agency (ies). 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. The term “Grant” is used to represent all forms of Federal financial assistance including but not limited to grants, cooperative agreements, loan guarantees, etc., unless otherwise excluded via Office of Management and Budget (OMB) guidance, Federal statute or regulation. If subsequent funding from one or more additional award instruments is used to supplement the initial real property investment, list all contributing award instruments.

3.Recipient Organization. Enter the name and complete address, including zip code, of the recipient organization.

4a. Dun and Bradstreet Data Universal Numbering System (DUNS) Number. Enter the recipient organization’s Data Universal Numbering System (DUNS) number or Central Contract Registry extended DUNS number. The DUNS number is also referred to as the Universal Identifier.

4b. Employer Identification Number (EIN). Enter the recipient organization’s Employer Identification Number (EIN) as assigned by the Internal Revenue Service.

5.Recipient Account Number or Identifying Number. Enter the account number or any other identifying number assigned by the recipient to the award. This number is strictly for the recipient’s use only and is not required by the Federal agency.

6.Contact Person for this Report. Enter the name, telephone number (including area code), e-mail address

and Facsimile number (including area code) of the person to contact on matters related to this report or request.

7.Report End Date. Enter the end date of the period for which the report is submitted using (MM/DD/YYYY) format. This block only applies when completing Attachment A.