These directions are intended to assist property owners in completing the HPI form to determine if their
property is eligible for listing in the National Register of Historic Places. Professional historic
preservation consultants should refer to the SHPO Survey Manual for instructions.
STREET ADDRESS: Provide the street address (101 Main Street) or the County or State Route number.
If possible include the rural address (Route 1, Box 25). If the address is unknown, provide other
locational information and include a map.
COMMON/HISTORIC NAME/BOTH: Place an “x” over the circle, or color the circle in to indicate if
the name is a common name or historic name, or both. A property’s “historic name” is a formal
designation and should reflect the event(s), or family, from which it derives its historic significance. The
“common name” is the designation by which the property is most generally known in the locale. In some
cases the names may be the same.
FIELD SURVEY #: Leave blank.
SITE # (SHPO ONLY): Leave blank unless SHPO Site number is known.
TOWN OR COMMUNITY: Include the name of the closest town or community. Include “vicinity of”
as necessary.
COUNTY: The name of the county where the property is located.
NEGATIVE NUMBER: Leave blank if not using film to photograph the property.
NR LISTED DATE: If applicable, enter the date the property was listed in the National Register.
ARCHITECT/BUILDER: Enter the name of the person responsible for the design of the building, if
known. And/or enter the name of the builder. Please indicate “architect” or “builder.”
DATE OF CONSTRUCTION: Enter date property was constructed. If this is an approximate date,
include “circa” before the year.
STYLE: Enter style of architecture or building type if known.
EXTERIOR SIDING/MATERIALS: Enter the exterior siding (stone, log, brick, clapboard, aluminum,
vinyl, etc.). If the property is not a building, enter the main material of construction.
ROOFING MATERIAL: Enter roof material (wood, asphalt, rubber membrane, slate, clay, etc.). For
bridges, enter deck material.
FOUNDATION: Enter foundation material (stone, concrete block, glazed tile block, poured concrete,
lumber posts, etc.). For bridges enter pier material.
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PROPERTY USE OR FUNCTION: Indicate how the property is currently being used. Place an X or
color in the circle next to residential or commercial property. Use a key word for other types of property
(school, church, bridge, industrial, site, vacant). Indicate any previous uses.
UTM NUMBER: Enter UTM or Latitude/Longitude coordinates, if known.
QUADRANGLE NAME: Enter the name of the United State Geological Survey Topographical
Quadrangle Map where the property is located, if known.
SURVEY ORGANIZATION & DATE: Organization or agency associated with documenting the
property. Leave blank if not preparing form in association with any organization or agency.
PART OF WHAT SURVEY/FR#: Name of the project the survey is associated with. Leave blank if
the documentation of the property is not associated with larger project.
PHOTOGRAPH: Photographs are not required to be included on the front page of the form.
Photographs can be embedded on continuation sheets or submitted separately as long as they are labeled.
Submission of electronic photographs is also helpful.
SITE PLAN: Using the space at the bottom of the front page to draw a site plan of the property showing
its relationship to its immediate environment. Include streets, alleys, rivers, streams, principal building,
outbuilding, etc. The arrow indicates that north is at the tope of the page.
SITE NUMBER: Leave blank unless SHPO Site number is known.
PRESENT OWNERS AND ADDRESS: Provide names of all current owners and their mailing address.
DESCRIBE SETTING: Provide a description of the property’s setting (city lot, rural farm, hillside,
river front, etc.). Describe trees, rock faces, or any landscape features that are present. Estimate the
number of acres. Indicate if known archaeological artifacts are present and describe current features.
DESCRIPTION OF BUILDINGS OR SITE (Original and Present): Describe the current and
historic physical appearance of the building(s), structure, or site. The description should be concise and as
specific as possible. Use continuation sheet as necessary.
ALTERATIONS: Check appropriate box. If answer is yes, please describe the type, date, and material
of alterations (such as, vinyl windows installed in 2000). Use continuation sheet as necessary.
ADDITIONS: Check appropriate box. If answer is yes, please describe the addition including date of
construction and materials. Use continuation sheet as necessary.
DESCRIBE ALL OUTBUILDINGS: Describe each outbuilding and/or ancillary resource located
within the historic property boundary. Include current and historic functions of all outbuildings included
with the property. Describe all outbuildings with date, siding, roof and foundation. Examples include
garages, barns, and sheds. Use continuation sheet as necessary.
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STATEMENT OF SIGNIFICANCE: Provide a history of the property and state how and why it is
significant. Use continuation sheet as necessary.
BIBLIOGRAPHICAL REFERENCES: Indicate any and all resource materials used in obtaining the
information contained on the form. Use continuation sheet as necessary.
FORM PREPARED BY: Provide the name, address, and phone number of the individual who
completed the form. Provide the date of completion.
CONTINUATION SHEETS: Please use continuation sheets for any additional information you are not
able to fit into the space on the form. Continuation sheets can also be used for extra photographs.
Return form to:
National Register and Survey Coordinator
The Culture Center
State Historic Preservation Office
1900 Kanawha Boulevard, East
Charleston, WV 25305-0300
West Virginia Division of Culture and History
State Historic Preservation Office
This program receives federal funds from the National Park Service. Regulations of the U.S. Department of the Interior prohibit unlawful
discrimination in departmental Federally Assisted Programs on the basis of race, color, national origin, age or handicap. Any person who believe 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.