Disaster Recovery Assistance Grant – Eligibility Form

Please fill out to the best of your ability – contact the SHPO with questions.

  1. Name of Property

Common name (can be N/A): ______

Historic names (if known):______

______

  1. Location

Street & number:______

City or town:______State:______Zip: ______County:______

______

  1. State Historic Preservation Office Certification (SHPO OFFICE USE ONLY)

As the designated authority under the National Historic Preservation Act, as amended,

I hereby certify that this request for determination of eligibility meets the documentation standards for registering properties in the National Register of Historic Places.

In my opinion, the property ___ meets ___ does not meet the National Register Criteria. I recommend that this property be considered significant at the following
level(s) of significance: ___national ___statewide ___local

Applicable National Register Criteria:

___A ___B ___C ___D

4. Summary Description

(Please provide a summary paragraph that briefly describes the general characteristics of the property, such as its location, style, method of construction, setting, size, and significant features in the space below.Much of this information can be found on your municipal assessor’s card. Provide at least one image of both the exterior and the interior for individual resources and five representative images (streetscapes and exteriors) for a district. Be sure to mention any character defining features such as original moldings, doors, windows, etc. Describe any major known renovations to the property since it was first built.

______

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  1. Statement of Significance

Please provide a short description of why the property is historically or architecturally significant. Is the property associated with a person who was significant to local, State or regional history? Did a significant event take place there? Does the property look similar to the way it did when it was originally constructed? What has changed and when?

5. Photographs

Submit clear and descriptive photographs. The size of each image must be 1600x1200 pixels (minimum), 3000x2000 preferred,at 300 ppi (pixels per inch) or larger. Each photograph must be numbered either captioned below or on the reverse of the printed photo and that number must correspond to the photograph number on the photo log.

Photo Log

Please list photo number, address, description of view, direction of view and date taken.

Ex. Photo 1 of 10 - 145 Main Street, façade or house, facing NW, 9/12/13

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