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(vgf,K£P- F-,cLD SHEC i/zlfli(tSil s-r: -3-OSEP(t co IN <br />Jame of Progeny County and State <br />10. Geographical Data <br />Acreage of Property _L `L 55 ('�`}�/ / 4CII2 c <br />UTM References <br />(Place additional UTM references on a continuation sheet.) <br />11 : I . i i 3 <br />Lone Easing Northing Zone Easlmg Northing <br />c I: _. _ 4 j' I I I. 11_ I I I ! I <br />See continuation sheet <br />Verbal Boundary Description <br />(Describe the boundaries of the property on a continuation sheet.) <br />Boundary Justification <br />(Explain why the boundaries were selected on a continuation sheet.) <br />11. Form Prepared By n _ <br />name/title —IU -4 .z. <br />v <br />organization ..� To lF�N= c. (�1L(rL ! �% /� � . S —7005, - <br />date <br />street & number . l7 S 3 So Tr telephone 37 - (o ( 6 3 _ <br />city or townASR �� teS _ state I N _ zip code <br />Additional Documentation <br />Submit the following items with the completed farm: _ <br />Continuation Sheets <br />Maps <br />A USGS map (7.5 or 15 minute series) indicating the property's location. <br />A Sketch map for historic districts and properties having large acreage or numerous resources <br />Photographs <br />Representative black and white photographs of the property. <br />Additional items <br />(Check with the SHPO or FPO for any additional items) <br />Property Owner <br />(Complete tt ,s item at the request of SHPO or FPO,) <br />name?6�Td �ND (�f�RKs R`cCdLfPr l (ON I Fl- IL 57 Cc FY12T uI1T <br />street & number 3;Q EPY5T (.WFK,7't9 STMT' _ telephone 5-1Y' o2Qq —y7(,S <br />city or town _ 30U7 1� ZtND state IN zip code LI6(0� Y <br />Paperwork Reduction Act Statement: This information is being collected for applications to the National Register of Historic Places to nominate <br />properties for listing or determine eligibility for listing. to list properties. and to amend existing listings. Response to this request :s required to obtain <br />a benefit in accordance with the National Historic Preservation Act, as amended (16 U.S.C. 470 et seq.) <br />Estimated Burden Statement: Public reporting burden for this form is estimated to average 16.1 hours per response including time for reviewing <br />instructions. gathering and maintaining data, and completing and reviewing the form. Direct comments regarding this burden estimate or any aspect <br />of this form to me Chief. Administrative Services Division. National Park Service, P.O. Box 37127. Washington, DC 20013-7127. and the Office of <br />Management and Budget. Paperwork Reductions Projects (1024.0015). Washington, DC 20503. <br />