Request For Certification Of Completed Work Form
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2MASSACHUSETTS HISTORICAL COMMISSION
STATE HISTORIC REHABILITATION TAX CREDIT PROGRAM
HISTORIC PRESERVATION CERTIFICATION APPLICATION
PART 3 – REQUEST FOR CERTIFICATION OF COMPLETED WORK
_________________________________________________
Property Name
_________________________________________________
Property Address
Project Number: _________________________
Instructions. Upon completion of the rehabilitation, return this form with representative photographs of the completed work (both exterior and
interior views) to the Massachusetts Historical Commission. A copy of this form will be provided to the Department of Revenue. Type or print
clearly in black ink. The decision of the Massachusetts Historical Commission with respect to certification is made on the basis of the descriptions in
this application form. In the event of any discrepancy between the application form and other, supplementary material submitted with it (such as
architectural plans, drawings and specifications), the application form shall take precedence.
1.
Name of property: ________________________________________________________________________________________________
Address of property:
Street___________________________________________________________________________________
City____________________________ County_______________________ State MA
Zip____________
Is property a certified historic structure?
yes
no
If yes, date of certification by MHC: __________________________
or date of listing in the National Register: ______________________
2.
Data on rehabilitation project:
Massachusetts Historical Commission assigned rehabilitation project number: ________________________________________________
Project starting date: ______________________________________________________________________________________________
Rehabilitation work on this property was completed and the building placed in service on: _____________________________________
Estimated costs attributed solely to rehabilitation of the historic structure: $ __________________________________________________
Estimated costs attributed to new construction associated with the
rehabilitation, including additions, site work, parking lots, landscaping: $ ___________________________________________________
3.
Owner: (space below for additional owners)
I hereby apply for certification of rehabilitation work described above for purposes of the State tax incentives. I hereby attest that the
information provided is, to the best of my knowledge, correct, and that, in my opinion the completed rehabilitation meets the Secretary of
the Interior’s “Standards for Rehabilitation” and is consistent with the work described in the Description of Rehabilitation. I also attest that
I own the property described above.
Name_______________________________ Signature _______________________________________ Date _______________________
Organization _____________________________________________________________________________________________________
Social Security or Taxpayer Identification Number ______________________________________________________________________
Street ___________________________________________________ City __________________________________________________
State ____________________________________ Zip ___________________ Daytime Telephone Number _______________________
Additional Owners:
Name___________________________________________________________________________________________________________
Street___________________________________ City____________________________________________________________________
State___________________ Zip____________________ Daytime Telephone Number ________________________________________
Social Security or Taxpayer Identification Number_______________________________________________________________________
Name___________________________________________________________________________________________________________
Street___________________________________ City____________________________________________________________________
State___________________ Zip____________________ Daytime Telephone Number ________________________________________
Social Security or Taxpayer Identification Number_______________________________________________________________________
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