Description of Building or Site (Original and Present)
__________Stories
_________Front Bays
(Use Continuation Sheets)
Alterations
If yes, describe
Yes
No
Additions
If yes, describe
Yes
No
Describe All Outbuildings
(Use Continuation Sheets)
Statement of Significance
(Use Continuation Sheets)
Bibliographical References
(Use Continuation Sheets)
Form Prepared By:
Date:
Name/Organization:
Address:
Phone #:
This program receives federal funds from the National Park Service. Regulations of the U. S. Department of the Interior prohibit unlawful discrimination in department Federally Assisted
Programs on the basis of race, color, national origin, age or handicap. Any person who believes he or she has been discriminated against in any program, activity, or facility operated by a
recipient of Federal Assistance should write to: Director, Equal Opportunity Program, U.S. Department of the Interior, National Park Service, P.O. Box 37127, Washington, D.C. 20013-7127.
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