OMB Control No.: 3090

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Expires: 07/31/2014

Standard Form 429 (9/2011) 

### i REAL PROPERTY STATUS REPORT SF

- 429

(COVER PAGE)

Page: of : Pages

1. Federal Agency and Organizational Element to Which

Report is Submitted: 2. Federal Gran t(s) or Other Identifying Number (s) Assigned by

Federal Agency (ies):

3. Recipient Organization ( n ame and complete address including zip code):

4a. DUNS Number: 4b. EIN: 5. Recipient Account or Identifying

Number: 6. Contact Person for this Report:

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 Report ing ) attach ed

___ : Attachment B ( Request to A cquire, I mprove or F urnish ) attached

___ : Attachment C (Disposition Request) attached

9 . Comments (attach additional sheets if necessary) :

1 0 . 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.

1 1 a. Typed or Printed Name and Title of Authorized Certifying

Official: 1 1 c. Telephone (area code, number, extension ):

1 1 d. Email A ddress:

1 1 b. Signature of Authorized Certifying Official: 1 1 e. Date R eport S ubmitted (MM/DD/YYYY):

1 2

. Agency use onlyOMB Control No.: 3090

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Standard Form 429 (9/2011) 

### ii 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: o f: 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):

1 3 . Period and type of Federal Interest (MM/DD/YYYY): From: To:

___ Acquisition ___ Renovation ___ Construction Government Furnished Property

1 4 a. Description of Rea l Property :

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

14 c. Land Acreage or Square Units:

Enter Amount:

________________ Select units: __ Acres __Square Feet

__Square Kilometers __ Square Meters 14 d. Gross and Usable Square F ootage / Meters (i.e., of building, house,

etc.):

Enter Amounts: Gross ___________ Usable ___________

Select Units: __ Square Feet __Square Meters

14 e. Real Property Ownership Ty pe (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):___________________________________________________

14 f . Real Property Cost: $ Share Percentage %:

Federal Share: $ [ %]

Non

- Federal Share: $ [ %]

Total (s um of Federal and Non

- Federal Share) : $ [ %]

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

___ Yes ___ No ___ N / A

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

14 h . Has Federally required i nsurance c overage been secured for this real property? ___ Yes ___ No

See instructions for more details

.

14 i . Are there any Uniform Relocation Act (URA) requirements applicable to this real property? ___ Yes ___ No

14 j . Are there any environmental compliance requirements related to the rea l property? ___ Yes ___ No

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

14 k

. 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 ( a ttach additional sheets if necessary):

1 5 . Has a significant change occurred with the real property

, or is there an anticipated change expected dur ing the next reporting period ? ___

Yes ___ No

If yes, describe the change ( a ttach additional sheets if necessary):

1 6 . Real Property Disposition Status:

___ A. Sold ___ B. Transferred to different award ___ C. Used in other Federa lly 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 fund s owed to

the Federal government :

ii. If applicable, e nter 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. Othe r (Specify)_______

1 8 . Remarks (attach additional sheets if necessary):

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

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Expires: 07/31/2014

Standard Form 429 (9/2011) 

### iii Real Property Status Report

ATTACHMENT B

( Request to Acquire, Improve or Furnish) SF

- 429

- B

Federal Grant or Other Identifying Number Assigned by Federal Agency ( #2 on cover page) Page : o f : Pages

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 p rovide information for each parcel of real property under the Federal financial assistance award identified in section 2):

1 3 a. Description of Real Property :

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

1 4 a. D escribe the intended use of the real property and how it will benefit the program (attach additional sheets if necessary):

14 b. 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):_____________________________________________

_________ 14 c. Proposed Acquisition Date (MM/DD/YYYY):

14 d. Land Acreage or Square Units:

Enter Amount:

________________ Select units: __ Acres __Square Feet

__Square Kilometers __ Square Meters 14 e. Gross an d Usable Square F ootage / Meters (i.e., of building, house,

etc.):

Enter Amounts: Gross ___________ Usable ___________

Select Units: __ Square Feet __Square Meters

14 f. Appraised Value (Valuation): $ Share Percentage %:

Federal Share: $ [ %]

Non

- Federal Share: $ [ %]

Total (sum of Federal and Non

- Federal Share) : $ [ %]

14 g. Are there any Uniform Relocation Act (URA) requir ements applicable to this real property? ___ Yes ___ No

14 h. Are there any environmental compliance requirements related to the real property? ___ Yes ___ No

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

14 i. In acco rdance 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 ( a ttach ad ditional 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 cons umption 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. W h a t is the anticipated c umulative energy use for the 12 months foll owing completion of the proposed acquisition/ construction/renovation project ?

A. Electric (kWh) _______or (Btu) _________ B. Petroleum (Gal ) _

_______ C. Natural Gas (cu ft) _______ D. Other (Specify)________

1 5 . Remarks (attach additional sheets if n ecessary):

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

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Standard Form 429 (9/2011) 

### iv Real Property Status Report

ATTACHMENT C

(Disposition or Encumbrance Request) SF

- 429

- C

Federal Grant or Other Ide ntifying Number Assigned by Federal Agency ( #2 on cover page) Page : o f : Pages

Complete the applicable blocks below for each parcel of real property for which you are seeking disposition or other instruct ions (duplicate this

page to provide informa tion 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” :

1 3 a. Description of Real Property :

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

13 c. Land Acreage or Square Units:

Enter Amount:

________________ Select units: __ Acres __Square Feet

__Square Kilometers __ Square Meters 13 d. Gross and Usable Square F oo tage / Meters ( i.e., of building, house,

etc.):

Enter Amounts: Gross ___________ Usable ___________

Select Units: __ Square Feet __Square Meters

1 4 a. Disposition Preference or Encumbrance Request [Check one]:

___A. Sell ___B. Transfer to differ ent award ___C. Use in other Federally sponsored project/program

D. Transfer title

___ E. Retain Title ___F . Encumber Property

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

14 c

. If this is a request to use the real property in other Federal

- sponsored projects/activities, describe the proposed use of the real property:

14 d. If this is a request to transfer title, identify the proposed receivi ng 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 p roperty? ___ Yes ___ No

If yes, describe them ( a ttach 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

l isting in the National Register of Historic Places? ___ Yes ___ No

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

14i. If this is a request to encumber the property, identify the party or parties to whom the propert y is propos ed to be encumbered and attach related

information (See instructions for more details) :

1 5 . 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

necess ary):

1 6 . Remarks (attach additional sheets if necessary):

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

- 429OMB Control No.: 3090

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Standard Form 429 (9/2011) 

### v INSTRUCTIONS FOR THE SF

- 429 Real Property Status Report

Public reporting burden for th is collection of information is estimated to average 24 0 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 in formation . Send

comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reduc ing this burden, to the

Office of Management and Budget, Paperwork Reduction Project (0348

- 0043), Washington, DC 20503.

Th is 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 Propert y (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 includ es real property that was

improved using Federal funds and real property that was d onated to a Federal project in the form of a match or

cost shar e 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 rep ort 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 A ttachment s 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 othe r

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 other wise 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 Universa l 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 Nu mber

(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 us e 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 th is 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 A ttachment A.OMB Control No.: 3090

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Standard Form 429 (9/2011) 

### vi 8

. Real Property Status Report

– Attachments. Check the ap plicable block(s) to indicate the type (s) of

attachment (s) being submitted (i.e., Attachment A = General Report ing , Attachment B = Request to Acquire, Improve

or Furnish, Attachment C = Disposition Request) and complete the related sections of the indica ted attachment(s)

for each parcel of real property being reported. Note that each attachment may be submitted using a single RPSR

if a recipient has a need to both report information and request instructions from an agency related to real

property unde r the same award instrument.

9

. Comments. Provide any special notes or comments regarding the real property being reported or the report

itself in this block. Comments should relate to issues not addressed in other sections of the report . Attach additional

sheets if necessary. If a negative report (no change in real property status) is being submitted for all parcels of real

property, enter the term “Negative” in this block. If there have been changes with some but not all parcels of real

prop erty, identify the parcels with negative status in this block (as follows: “Negative s tatus for the following

Properties: ”) and provide the related attachment(s) for each parcel with changes to report.

1 0

. Certification. By signing this report (block 1 1 b. )

, the recipient is certifying that to the best of their knowledge

and belief

, the information contained in this report is true, correct and accurate and constitutes a material

representation of fact upon which the Federal government may rely. Note t hat a false statement of fact in this

report may constitute a violation of Federal law and may be grounds for possible punishment as provided in

18 U.S.C. 1001.

1 1 a. Typed or Printed Name and Title of Authorized Certifying Official. Enter the full name and title of the

authorized certifying official.

1 1 b. Signature of Authorized Certifying Official. The authorized certifying official must sign here certifying

to the facts presented in the report. A copy of the governing body’s authorization for th e certifying official

to sign official documents on behalf of their organization as an official representative must be on file in the

recipient’s office. (See item 1 0. above.)

1 1 c. Telephone. Enter the telephone number (including area code and ext ension) of the individual listed in section

1 1 a.

1 1 d. Email address. Enter the email address of the individual listed in section 1 1 a.

1 1 e. Date report submitted. Enter the date the report is submitted to the Federal agency using the

following format ( mm/dd/yyyy).

1 2

. Agency use only. This section is reserved for Federal agency use only.OMB Control No.: 3090

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Standard Form 429 (9/2011) 

### vii B. Instructions Related to Attachment A (General Reporting) follows:

Real Property Details. Provide the requested information in subsections 1 3 through 1 8 of A ttachment A for each

parcel of real property being reported. Use a separate sheet to report information on each parcel of real property

under the Federal financial assistance award identified in section 2. If a section does not appl y, enter “N/A.”

Below is a summary of the required information to be provided for each subsection of A ttachment A:

1 3

. Period and type of Federal Interest. Enter the period, established in the award document, during which Federal

interest in the real property begins (i.e., From) and ends (i.e., To) using (MM/DD/YYYY) format. [ex., From:

03/23/2005 To: 03/22/2025]. This period may exceed the grant award performance period in those instances

where Federal interest continues beyond the end of the cur rent award. In some instances the end date for the

period of Federal interest may not be defined by a specific date. If that is the case, enter the beginning date

along with a statement to indicate the planned or uncertain end date (ex. “From: 03/23/2 005 To: Expiration

of Federal Interest”). Check the appropriate box indicating the action the Interest is tied to. Federal Agencies

will define the applicable begin ning date.

1 4 a. Description of Real Property. Describe the type of real property being reported (i.e., land, building, etc.)

and provide a useful description of the real property (i.e., building number 17 at the National Research Center,

Chapel Hill, NC). If the real property is being renovated or altered, also describe the nature of the work (i.e.

, major

renovation of building 17, wing c).

1 4 b. Address of Real Property. Enter the legal description and complete address for each parcel of real

property being reported including the street, city, state, county/parish, country, zip code, a nd physical location if an

address is not available (i.e., latitude, longitude, lot number, parcel number, etc.). Also, indicate zoning information

related to the real property (i.e., mixed use, residential, commercial, etc.). Where an address is not av ailable, or

more precision is required, geographic coordinates may be used. Locational data should be recorded with a Global

Positioning System (GPS) device set to NAD 83, or WGS 84 datum using either of the following coordinate

reference systems:

**•** Uni ted States National Grid (USNG) using the full grid zone designation and a minimum of eight digits

.

**•** Decimal degrees latitude and longitude, with at least 6 decimal places and a minus (

- ) to show west

longitude or south latitude.

1 4 c. Land Acreage or Squar e Kilometers

. Enter the size of the land or the size of the land on which the

real property is located in terms of measured acreage or square unit s (i.e., 1.5 acres, 0.8 sq. km., etc .).

Identify the unit of measure. Use only one option, either acres, s quare kilometers, square feet, or square meters.

1 4 d. Gross and Usable Square F oo t age / Meters (i.e., of building, house, etc.). Enter the gross and usable

square f oo t age / meters for each structure (i.e., of the building, house, etc.) being reported. Identi fy the unit of

measure. Select only one, either square feet or square meters.

1 4 e. Real Property Ownership Type (s)

. Check the applicable box (es) to indicate the real property ownership type (s)

. If more than one type is applicable, check all that apply

. If the ownership types listed do not apply, check

“ J . Other” and describe the ownership arrangement. Example of Other: Conservation Easement.

1 4 f

. Real Property Cost. Enter the total cost of the real property acquired (purchase price only) or improved

, including the following data . If multiple Federal agencies are contributing to the acquisition or improvement of the

real property, attach a separate sheet to identify each agency and their contribution using the format below:

1. Amount provided by the Federal government (i.e., Federal Share of Property Cost based on the Federal

2. share of the total cost of the program or project),

3. Share percentage provided by the Federal government (i.e., Federal Share Percentage of Property Cost

4. based on the Federal s hare of the total cost of the program or project),

5. Amount provided by the recipient or other non

- Federal entities (i.e., non

- Federal Share of Property Cost),

6. Share percentage provided by the non

- Federal entities, (i.e., non

- Federal Share Percentage of Pro perty Cost),

7. Total cost (i.e., Sum of Federal and non

- Federal Share of the Property Cost), and

8. Total share percentage (i.e., sum of share percentages of Federal and non

- Federal Share of the Property

9. Cost must equal 100%).OMB Control No.: 3090

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Standard Form 429 (9/2011) 

### viii 1 4 g

. Has a deed, lien, covena nt, or other related documentation been recorded to establish Federal interest

in this real property? If yes (unless previously reported) , describe the instrument used and enter

the date and jurisdiction in which it was recorded. Check either “yes” or “no” to indicate if the documentation

has been recorded. If the awarding agency has not imposed the requirement to record Federal interest in the

real property

, check “NA”. If Federal interest has been recorded, enter the instrument used (i.e., deed, l ien,

covenant, etc.) along with the date and jurisdiction in which it was recorded (ex., Executed on 01/04/2007, in the

Arlington, VA County Clerk’s office, Deed book #54987, page 234). T he recordation of Federal interest in real

property must be report ed by no later than the next scheduled reporting date after the real property has

been acquired, improved or donated

, or as directed by the awardin g agency in the award document. The

recipient must maintain records of the recordation of Federal interest in real property and make such records

available upon the request of the Federal government.

1 4 h

. Has Federally Required Insurance Coverage been secured for this real property? Check either

“yes” or “no” to indicate if Federally required insurance ha s been secured for the real property

. The recipient

must maintain records of the insurance coverage that has been secured for the real property and make the

records available upon the request of the Federal government. Note: R ecipients must provide ins urance coverage

for any real property acquired under a Federal financial assistance award that is, at a minimum, equivalent

to insurance coverage that the recipient provides for other real property they own.

1 4 i

. Are there any Uniform Relocation Act (URA) requirements applicable to this real property? If the

acquisition or development of the real property involved the movement of any person permanently from real

property or the movement of personal property from real property directly because of a cquisition, rehabilitation, or

demolition for an activity undertaken with Federal assistance , the Uniform Relocation Act (URA) requirements

may apply. Indicate if the Act appl ies by checking “yes or no”. If the Act does apply, the recipient must mainta in

records of compliance and make such information available upon the request of the Federal government.

1 4 j

. Are there any environmental compliance requirements related to the real property? If yes, d escribe

them. C heck either “yes” or “no” to indi cate if there are any environmental compliance requirements related to the

real property. Describe any environmental compliance requirements related to the real property. The recipient

must maintain records of compliance with all environmental requirem ents related to the real property and make

such information available upon the request of the Federal government. Attach additional sheets if necessary

.

14 k

. In accordance with the National Historic Preservation Act (NHPA), does the property

possess hi storic significance, and/or is it listed or eligible for listing in the National Register of

Historic Places? If yes, d escribe them. In accordance with Section 106 of the National Historic Preservation

Act (NHPA), does the property possess historic sign ificance, and/or is it listed or eligible for listing in the National

Register of Historic Places? Describe any historical significance, National Register of Historic Places listing or

eligibility for such listing

, related to the real property. Note, an y property listed in, or eligible for listing in the National

Register of Historic Places is considered historic. S ection 106 protections also **extend** to properties that

**possess significance** but have not yet been listed or formally determined eligible for listing.

1 5

. Has a significant change occurred with the real property

, or is there an anticipated change expected

during the next reporting period ? Check the applicable block to indicate either “yes” or “no.” If a significant

change has occurred (or is anticipated to occur during the next reporting period) , such as a major building

renovation or remodeling, damage to the real property due to an act of God (flood, hurricane, earthquake,

etc.) or other significant change that would affect the value of the property , describe the change. Attach

additional sheets if necessary

. Note: If a sig nificant change has occurred, 14 f

. should be recalculated to reflect

the change in Federal i nterest , if any

.OMB Control No.: 3090

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Standard Form 429 (9/2011) 

### ix 1 6

. Real Property Disposition Status. Check t he appropriate block (A

– F ) to indicate the type of disposition

status being reported , if any

. i

. If the Federal agency provided the recipient with disposition instructions to sell or retain title to the

real property, enter the amount of funds owe d to t he Federal government. Enter the amount of funds

owe d to the Federal government as compensation for the Federal interest in the real property if the awarding

agency either directed the recipient to sell or granted them permission to retain title to the r eal property.

ii. If applicable, e nter the amount of any net proceeds from the sale of the real property and

describe how the proceeds were distributed. If applicable, enter the amount of any net proceeds from the

sale of the real property and indicate if they were returned to the Federal government, used as an offset

toward the cost of acquiring replacement real property for the project or program, or used to offset the original

cost of the real property if the award is still active. If not applicable enter “NA.”

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

funds the Federal agency owe s

. If the recipient w as directed to transfer title to either the Federal agency or

to a third party identified by the Federal agency , enter the amount of funds the Federal agency owe s the

recipient as compensation for their interest in the real property (i.e., the percentage of the recipient’s

participation in the project cost multiplied by the fair mar ket value of the real property at the time of

disposition).

17. Indicate the cumulative energy consumption for the previous 12 months. Complete the appropriate

block (A

– D) to indicate the actual cumulative energy consumption for the property during pe rvious 12

months

.

**•** Cumulative Energy Use may be obtained from the facility utility bills or outreach to the utility provider. Depending on the

locality, the bill may include only the current month or may include the total for the 12 months prior and pos t project completion.

When the grantee is one tenant in a multi

- tenant facility AND separate utility metering is not in place, pro rata estimating is

appropriate The anticipated energy consumption, post completion for new construction and renovation proje cts, should be

available in the project plan. Use of the Portfolio Manager tool, a free application, is encouraged for the tracking of ene rgy

consumption data . ( http://www.energystar.gov/index.cfm?c=evaluate_performance.bus_portfoliomanager )

1 8

. Remarks. Enter any explanations deemed necessary or information required by the Federal agency including

any remarks that the recipient would like to make to add ress issues that are not addressed elsewhere in this

report. Attach additional sheets if necessary

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Standard Form 429 (9/2011) 

### x C

. Instructions Related to Attachment B (Request to Acquire, Improve or Furnish) follows:

Real Property Details. Complete the applic able information in subsections 1 3 a. through 1 5 . of A ttachment B for each

parcel of real property for which the recipient is requesting the authority to acquire , improve

, or be provided as

Government Furnished Property (GFP)

. This attachment should only be used if the applicable program authority

or budget allows recipients to acquire, improve or furnish real property

. Use a separate sheet for each parcel of

real property under the Federal financial assistance award identified in section 2. With the ex ception of 1 5 , all

sections are required to be completed for all requests

. Below is a summary of the required information to be provided

for each subsection of Attachment B :

1 3 a. Description of Real Property. Describe the type of real property being re ported (i.e., land, building, etc.)

and provide a useful description of the real property (i.e., building number 17 at the National Research Center,

Chapel Hill, NC). If the real property will be renovated or altered, also describe the nature of the work (i.e.

, major

renovation of building 17, wing c).

13b

. Address of Real Property. Enter the legal description and complete address for each parcel of real property

including the street, city, state, county/parish, country, zip code, and physical locatio n if an address is not available

(i.e., latitude, longitude, lot number, parcel number, etc

. Also, indicate zoning information related to the real property

(i.e., mixed use, residential, commercial, etc.). Where an address is not available, or more precis ion is required,

geographic coordinates may be used. Locational data should be recorded with a Global Positioning System (GPS)

device set to NAD 83, or WGS 84 datum using either of the following coordinate reference systems:

**•** United States National Grid (USNG) using the full grid zone designation and a minimum of eight digits.

**•** Decimal degrees latitude and longitude, with at least 6 decimal places and a minus (

- ) to show west

longitude or south latitude.

14 a. D escribe the intended use of the real propert y and how it will benefit the program. Describe how

the recipient intend s to use the real property that they want to acquire, improve or furnish to support the program

under which it is being funded. Describe how the acquisition, improvement or furnishi ng (as applicable) of the real

property will benefit the program in quantifiable terms (ex., lower cost than renting or purchasing with a comparison

of the two, improved service delivery using benchmarks to demonstrate anticipated improvements, etc.). At tach

additional sheets if necessary.

1 4 b. Proposed Real Property Ownership Type (s)

. Check the applicable box (es) to indicate the proposed real

property ownership type (s)

. If more than one type is applicable, check all that apply, If the ownership t ypes listed

do not apply, check “ J . Other” and describe the proposed ownership arrangement. Example of “Other”: Conservation

Easement.

1 4 c. Proposed Acquisition Date. Using (MM/DD/YYYY) format, enter the proposed date for the real property

acquisition or improvement, or the date the recipient would like the government to furnish real property.

14d

. Land Acreage or Square Kilometers

. Enter the size of the land or the size of the land on which the real

property is located in terms of measured acre age or square unit s (i.e., 1.5 acres, 0.8 sq. km., etc.). Identify the unit

of measure. Use only one option, either acres, square kilometers, square feet, or square meters.

14e

. Gross and Usable Square F oo t age /Meters (i.e., of building, house, etc.). E nter the gross and usable

square f oo t age / meters of each structure (i.e., of the building, house, etc.) being reported

. Identify the unit of

measure. Select only one, either square feet or square meters.

14f

. Appraised Value (Valuation). Enter the apprais ed value (valuation) of the real property to be acquired

(purchase price only), or the cost of proposed improvements, including the following. If multiple Federal agencies

will contribute to the acquisition or cost to improve the real property, attach a separate sheet to identify each agency

and their contribution using the format below:OMB Control No.: 3090

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### xi 1. Amount to be provided by the Federal government (i.e., Federal Share of Appraised Property Value or

estimated improvement cost based on the Federal share of t he total cost of the program or project),

2. Share percentage to be provided by the Federal government (i.e., Federal Share Percentage of

Appraised Property Value or estimated improvement cost based on the Federal share of the total cost of the

program or project),

3. Amount to be provided by the recipient or other non

- Federal entities (i.e., non

- Federal Share of Appraised

Property Value or estimated improvement cost),

4. Share percentage to be provided by the non

- Federal entities, (i.e., non

- Federa l Share Percentage of

Appraised Property Value or estimated improvement cost),

5. Total cost (i.e., s um of Federal and non

- Federal Share of the Appraised Value or estimated improvement

cost of the property), and

6. Total share percentage (i.e., sum o f share percentages of Federal and non

- Federal Share of the

Appraised Property Value or estimated improvement cost).

14g

. Are there any Uniform Relocation Act (URA) requirements applicable to this real property? If the

acquisition or development of the real property that is the subject of this request involves the movement

of any person permanently from real property or the movement of personal property from real property directly

because of acquisition, rehabilitation, or demolition for an activity u ndertaken with Federal assistance , the Uniform

Relocation Act (URA) requirements may apply. Indicate if the Act does apply by checking “yes or no.” If the Act

does apply, the recipient must maintain records of compliance and make such information avail able upon the

request of the Federal government.

14h

. Are there any environmental compliance requirements related to the real property? If yes, describe

them. Check either “yes” or “no” to indicate if there are any environmental compliance requiremen ts related to the

real property. Describe any environmental compliance requirements related to the real property

. The recipient

must maintain records of compliance with all related environmental compliance requirements and make

such information availa ble upon the request of the Federal government. Attach additional sheets if necessary.

1 4 i



### . 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? If yes, d escribe them. In accordance with the Section 106 of the National Historic Preservation Act

(NHPA), does the property possess historic significance, and/or is it listed or eligible for listing in the Na tional

Register of Historic Places? Describe any historical significance, National Register of Historic Places listing

or eligibility for such listing, related to the real property. Note, any property listed in, or eligible for listing

in the National Register of Historic Places is considered historic. Section 106 protections also **extend** to

properties that **possess significance** but have not yet been listed or formally determined eligible for listing.

14j. D oes the proposed action employ green/sustain able practices (check all that apply)? Check each

block which applies (A

– E) to indicate the green/sustainable practices (if any) that will be employed when the

proposed real property is acquired, constructed or renova t e d.

A. Employs Integrated Des ign Principles includes a collaborative, integrated planning and design process and

commissioning. ( https://www.wbdg.org/design/engage_process.php )

.

B. Enhances Indoor Environmental Quality i ncludes ventilation and thermal comfort, moisture control, daylighting, low

emitting materials, protection of indoor air quality during construction, and environmental tobacco smoke control

( http://www.wbdg .org/design/ieq.php ).

C. Protects and Conserves Water includes potable and non

- potable indoor water

( http://www.wbdg.org/design/dd_plumbingeng.php ), outdoor water in landscape, irrigation, and storm runoff

( http://www.wbdg.org/design/dd_landscapearch.php ) , process water, and water

- efficient products such as EPA

WaterSense products ( http:/ /www.epa.gov/watersense ).

D. Reduces Environmental Impact of Materials includes recycled content ( www.epa.gov/cpg ), biobased content

( www.usda.gov/biopreferred ), envi ronmentally preferable products (www.wbdg.org/design/greenspec.php), water and

materials management, and elimination of ozone depleting compounds ( http://www.wbdg.org/design/greenspec.php ).OMB Control No.: 3090

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Standard Form 429 (9/2011) 

### xii E. Opti mizes Energy Performance includes energy efficiency ( http://www.wbdg.org/references/mou_ee.php )

( http://www.wbdg.org/design/dd_hvaceng.php ) that takes into account intended use, occupancy, plug loads, on

- site

renewable energy, measurement/verification, benchmarking, and where available using Energy Star®

( http://www.e nergystar.gov/index.cfm?fuseaction=find_a_product ) and Department of Energy

- designated energy efficient

products ( http://www1.eere.energy.gov/femp/technologies/eep_purch asingspecs.html ).

14k. What was the cumulative energy consumption for the facility in the past 12 months? Complete the

appropriate block (s) (A

– D) to indicate the actual cumulative energy consumption for the property during pervious

12 months. If thi s is a request to be furnished real property (GFP), unless you already have the information, in sert

“NA” in block D.

**•** Cumulative Energy Use may be obtained from the facility utility bills or outreach to the utility provider. Depending on the locality,

th e bill may include only the current month or may include the total for the 12 months prior and post project completion. When the

grantee is one tenant in a multi

- tenant facility AND separate utility metering is not in place, pro rata estimating is appropr iate The

anticipated energy consumption, post completion for new construction and renovation projects, should be available in the proj ect

plan. Use of the Portfolio Manager tool, a free application, is encouraged for the tracking of energy consumption da ta.

( http://www.energystar.gov/index.cfm?c=evaluate_performance.bus_portfoliomanager )

14l. What is the anticipated cumulative energy use for the 12 months following completion of the

proposed acquisition/ construction/renovation project? Complete the appropriate block(s) (A

– D) to indicate the

anticipated cumulative energy use for the property after the property is acquired, constructed, renovated or furni shed as GFP.

15

. Remarks. Enter any explanations deemed necessary or information required by the Federal agency including

any remarks that the recipient would like to make to address issues that are not addressed elsewhere in this request.

Attach addi tional sheets if necessary.OMB Control No.: 3090

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Standard Form 429 (9/2011) 

### xiii D. Instructions Related to Attachment C (Disposition or Encumbrance Request) follows:

Real Property Details. Complete the applicable information in subsections 1 3 a. through 1 6 . of A ttachment C for

each pa rcel of real property for which the recipient is requesting disposition /encumbrance or other instructions. Use a

separate sheet to request disposition /encumbrance or other instructions on each parcel of real property under the

Federal financial assistan ce award identified in section 2. If a section does not apply, enter “N/A.” Below is a summary

of the required information to be provided for each subsection of A ttachment C :

1 3 a. Description of Real Property. Describe the type of real property that i s the subject of this request (i.e., land,

building, etc.) and a useful description of the real property (i.e., building number 17 at the National Research Center,

Chapel Hill, NC).

13b

. Address of Real Property. Enter the legal description and comple te address for each parcel of real property

including the street, city, state, county/parish, country, zip code, and physical location if an address is not available

(i.e., latitude, longitude, lot number, parcel number, etc.). Also, indicate zoning inf ormation related to the real

property (i.e., mixed use, residential, commercial, etc.). Where an address is not available, or more precision is

required, geographic coordinates may be used. Locational data should be recorded with a Global Positioning

S ystem (GPS) device set to NAD 83, or WGS 84 datum using either of the following coordinate reference systems:

**•** United States National Grid (USNG) using the full grid zone designation and a minimum of eight digits.

**•** Decimal degrees latitude and longitude, wi th at least 6 decimal places and a minus (

- ) to show west

longitude or south latitude.

13c

. Land Acreage or Square Kilometers

. Enter the size of the land or the size of the land on which the real

property is located in terms of measured acreage or squar e uni ts (i.e., 1.5 acres, 0.8 sq. km., etc.). Identify the unit

of measure. Use only one option, either acres, square kilometers, square feet, or square meters.

13d

. Gross and Usable Square F oo t age /Meters (i.e., of building, house, etc.). Enter the gro ss and usable square

footage/ meters for each structure (i.e., of the building, house, etc.) being reported. Identify the unit of measure. Select

only one, either square feet or square meters.

1 4 a. Disposition Preference or Encum b rance Request [Check one]

. Check the appropriate block (A

– F ) to indicate

the type of disposition /encumbrance instruction preference being requested. The award document will indicate the

disposition option(s) available. The recipient may not request a disposition preference that is not already allowed under

the award. Agencies will respond timely to all requests via letter, electronic mail and/or other appropriate means

.

1 4 b. If this is a request to transfer Federal Interest to a different award, specify the proposed grant number

and funding agency. If the recipient is proposing to transfer the Federal interest to a different award, specify the

grant number and funding agency for the award to which the recipient is proposing to transfer the interest.

14c

. If this is a req uest to use the real property in other Federal

- sponsored projects/activities, describe the

proposed use of the real property. If the recipient is proposing to use the real property to provide services or

facilities for other Federal

- sponsored projects o r activities, identify the other Federal projects or activities and how

the real property will be utilized. Also, describe any impact expected on the host Federal project or activity due to

the proposed additional use of the real property. Attach addit ional sheets if necessary.

1 4 d

. If this is a request to transfer title, identify the proposed receiving entity . If applicable, provide contact

information for the proposed receiving entity.OMB Control No.: 3090

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Standard Form 429 (9/2011) 

### xiv 14e. Appraised Value. Enter the third party appraised value of the real property (current market value), including

the following:

1. Amount provided by the Federal government (i.e., Federal Share of Appraised Property Value cost based

on the Federal share of the total cost of the program or project),

2. Share percentage provided by the Federal government (i.e., Federal Share Percentage of Appraised Property

Value based on the Federal share of the total cost of the program or project),

3. Amount provided by the recipient or other non

- Federal entiti es (i.e., non

- Federal Share of Appraised

Property Value)

, 4. Share percentage provided by the non

- Federal entities, (i.e., non

- Federal Share Percentage of Appraised

Property Value)

, 5. Total cost (i.e., Sum of Federal and non

- Federal Share of the Appra ised Value)

, and

6. Total share percentage (i.e., sum of share percentages of Federal and non

- Federal Share of the Appraised

Property Value).

1 4f

. Are there any Uniform Relocation Act (URA) requirements applicable to this real property? If the

acqui sition or development of the real property involved the movement of any person permanently from real property

or the movement of personal property from real property directly because of acquisition, rehabilitation, or demolition

for an activity undertake n with Federal assistance , the Uniform Relocation Act (URA) requirements may apply. Indicate

if the Act does apply by checking “yes or no”. If the Act does apply, the recipient must maintain records of compliance

and make such information available upo n the request of the Federal government.

1 4g



### . Are there any environmental compliance requirements related to the real property? If yes, describe

them. Check either “yes” or “no” to indicate if there are any environmental compliance requirements relate d to the

real property. Describe any environmental compliance requirements related to the real property. The recipient

must maintain records of compliance with all environmental requirements related to the real property and make such

i nformation avail able upon the request of the Federal government. Attach additional sheets if necessary

.

1 4h

. 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? If yes,

d escribe them. In accordance with the Section 106 of the National Historic Preservation Act (NHPA), does the

property possess historic significance, and/or is listed or eligible for listing in the Natio nal Register of Historic Places?

Describe any historical significance, National Register of Historic Places listing or eligibility for such listing, related t o

the real property. Note , any property listed in, or eligible for listing in the National Regis ter of Historic Places is

considered historic. Section 106 protections also **extend** to properties that **possess significance** but have not yet

been listed or formally determined eligible for listing.

14

. i. If this is a request to encumber the property, i dentify the party or parties to whom the property is

proposed to be encumbered and attach related information: Identify the party /part ies to whom the property

is proposed to be encumbered and attach the proposed form and terms of encumbrance, a long with a copy of

any proposed subordination, inter

- creditor agreement, or other documentation to protect the interests of the

U.S. Government in case of default.

1 5

. If this is a request for a release from the obligation to report on the real property, descri be the

reasons for the request. Describe the recipient’s reasons for requesting a release from the obligation to report.

Examples of acceptable reasons include but are not limited to expiration of Federal interest or the real property

being disposed o f in accordance with agency direction. Attach additional sheets if necessary.

1 6

. Remarks. Enter any explanations deemed necessary or information required by the Federal agency including

any remarks that the recipient would like to make to address issu es that are not addressed elsewhere in this request.

Attach additional sheets if necessary.