Fillable Printable Form 55031
Fillable Printable Form 55031
Form 55031
REVIEW REQUEST SUBMITTAL
State Form 55031 (R / 4-17)
Indiana Department of Natural Resources
Division of Historic Preservation and Archaeology, Indiana State Historic Preservation Office (SHPO)
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Please complete this form and attach it to the front of all submittals, along with any reports or supplemental materials
you are providing to the Indiana DHPA for review. Please note that archaeologi cal an d structural information can be
submitted together but should be separate documen ts since archaeological site locations are confidential and not for
public disclosure.
Date (month, day, year): ________________________ ____
This is a new submittal.
This is revised/additional information relating to DHPA num ber ________________________.
This project is being undertaken pursuant to the terms and conditions of a progr ammatic or other interagency agr eement.
Title of Agreement: ___________ ___________________________ __________________________ _________________
This project will also be applying for F ederal Rehabilitation Investment Tax Credit.
This project includes work on a property that is under a preservation covenant held by DHPA.
THIS REVIEW REQUEST SUBMITTED BY:
Name: _________________________________________________________________________________ ______________
Company/Organization: ___________________________ ______________________________________ ________________
Address (number and street): _____________________________________________________________________________
City: ________ ___________________________ ____ State: ________________ ZIP: ________________
Telephone number: ___ ____________________________
E-mail address: _______________________________ __
PROJECT NAME & LOCATION [Please attach a map with location(s) marked]
Project Name/Reference:______ ______________ _________________________ Project/Des Number: ______________ ___
Project Address/Location: ___ _______________ ______________________________________________________________
City: ________ _______________ ___________________ Township(s):_____________________________________
County/Counties: _____________________________________________________ __________________________________
Section/Township/Range: _____________________________________ ______________________________________ _____
Latitude/Longitude: _____________ ________________________________________________________________________
STATE OR FEDERAL AGENCY INVOLVEMENT
Agency: _____ __________________________________ Program: _______________________________________
Type of funds, license, or permit to be obtained (if applic able): _________ __________________________________________
Name of Agency Contact: _______ ___________________________ __________________________ __________________
Address (number and street): ____________________________________________________________________________
City: ________ ___________________________ ____ State: ________________ ZIP: ________________
Telephone number: ____ _________________________
E-mail address: _______________________________ __
Reset Form
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APPLICANT (if different than Federal Agen cy) If available, please attach copy of authorization letter from federal
agency.
Applicant: ___________________________________________________________ ________________________________
Name of Contact: _____________________________________________ ________________________________________
Address (number and street): ____________________________________________________________________________
City: ________ ___________________________ ____ State: ________________ ZIP: ________________
Telephone number: ____ __________________________ E-mail address: _______________________________ _
ADDITIONAL CONTACT (IF APPLICABLE)
Name of Contact: _____________________________________________ ________________________________________
Organization/Agency: ______________________________________________________________ ____________________
Address (number and street): ____________________________________________________________________________
City: ________ ___________________________ ____ State: ________________ ZIP: ________________
Telephone number: ___ ____________________________ E-mail address: ________________________________
Project Description
–
This should include a detailed scope of work, including any acti ons to be taken in relation to the
project, such as all aspects of new construction, replacement/repair, demolition, gr ound disturbance, and all ancillary work
(temporary roads, etc.), as applicable. Attach report or additi onal pages if necessary. If a detailed scope of work is not
available yet, please explain and include all preliminary infor m ation.
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Ground Disturbing Activity
–
This should include a d etailed description of all horizontal and vertical ground disturbance in
relation to the project as well as an y known previous and current land use, condition, and disturbances. Attach report or
additional pages if necessary. Indicate if the project does not include any ground disturbing activities. Please note that
agricultural tilling generally does not have a serious enough impact on ar chaeological sites to constitute a disturbanc e of the
ground for this purpose.
FINDINGS – Please note that a finding should only be submitted when the agenc y/delegatee believes it is appropriat e or one
has been requested by our office. Only those who represent the Federal Agency or an official delegatee of the federa l agency
are authorized to make findings of effect for an undertaking.
No Historic Properties Affected – (i.e., none ar e present or there are historic properties present but the pro ject will have no
effect upon them). Attach necessary documentation, as des cribed at 36 CFR 800.11.
No Adverse Effect – The proposed undertaking will have no adverse effect on one or more histor ic properties located within
the project APE under 36 CFR 800.5. Attach necessary documentation, as described at 36 CFR 80 0.11.
Adverse Effect – The proposed undertaking will result in an adverse effect to one or more historic properties and the
applicant, or other federally authorized representative, will consult with the SHPO and other consulting parties to resolve the
adverse effect per 36 CFR 800.6. Attach necessary documentation, as described at 36 CFR 800.11, with a proposed plan to
resolve adverse effect(s).
Please explain the basis for your dete rmination.
Authorized Signature: ________________________________________________ Date (month, day, year): ______________
Type or print name: _______________________________________________________ _______________________________
Organization/Agency: ______________________________________________________________ ______________________
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Please note that incomplete sub missio ns may result in delays. To ensure an expeditious review, please be sure that
the following has been provided:
Completed Review Request Submittal Form
Letter of authorization from Federal agency/agencies (if applicable)
Consulting Parties – List of all consulting parties that have b een invited to participate and copies of any re sponses received.
Typical consulting p arties would include the county historian, local historica l society, the appropriate regional office of Indiana
Landmarks, other local, state or national preservatio n orga nizations, tribes, local government and the general public.
Map of project location with project area(s) and Are a of Potential Effects (APE) clearly marked, streets labe led and a north
arrow, aerial maps are preferable and areas of previous ground disturbance within the project area should be shown. Please
indicate if any of the project area is located on state or federal property.
Clear, current color photographs of project area and APE, including any buildings or structures fifty (50) years or older within
the APE. (No more than two (2) photographs per page, for large project areas/APEs photographs can be provided digitally
on a CD but must be clearly labeled.)
Architectural/Engineerin g Drawings (if applicable) – Must be labeled with north arro w, clearly indicate proposed changes to
existing buildings and locations of any ground disturbanc e on site plans. When possible include both existing and propose d
drawings. Hard copies should be provided at no smaller than 11” x 17” and font must be legible; if the drawings are large
scale reduced to 11” x 17”, please also provide a CD with a PDF copy of the drawings.
Identification of any known historic resources – All projects should consult the SHAARD database (access avail able on the
DHPA home page) to locate known historic resources in the project area and APE. For any identifi ed resources, the
submission should include (in summary form) a list of the properties identified, including address, the site/reference number
from SHAARD, the rating (IHSSI, Bridge Inventory) or status (National Register) of each property, and a current photograph.
Please do not submit print outs of the individ ual SHAARD records.
Please note that at this time we are unable to accept electronic submissions. The thirty (30) day review period, as
specified in 36 CFR part 800.3(c)(4), begins from the date that we receive the hard copy of the submission.
Return this Form and Attachments to:
Indiana Department of Natural Resources
Division of Historic Preservation and Archaeology
402 W. Washington Street, Room W274
Indianapolis, In diana 46204
http://www.in.gov/dnr/historic
