ATTESTATION FORM — CHECK ONE, ENTER SSN, AND CLICK SUBMIT

There have been no occurrences since my last renewal which either (a) are subject to the reporting requirements described in the Guidelines* or (b) mean that I no longer meet the criteria for continued listing in the National Register.
— OR —
I have (a) briefly described any reportable matters as described in the Guidelines* and (b) have submitted a copy of the final result or described the current status and submitted key documents.

I hereby attest that my response to the applicable preceding statement is true, complete, and accurate to the best of my belief.

By signing this Attestation, (1) you certify that you have read this Attestation and applied a valid, legal signature, (2) you agree to be governed by all of the terms of this Attestation.

PRINT NAME

 

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SIGNATURE

 

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DATE _________________

* The Guidelines appear on our web site www.nationalregister.org.

RENEWAL IS NOT COMPLETE WITHOUT ATTESTATION FORM