ࡱ>  ގbjbj 8) 8 d3GL(F*v*L+(EFFFFFFCIK*F,(NF*,,F F444,XE4,E44RCD p?y5l/CEG03GCM08M(DMDD0+"R+4j+~+0+0+0+FF>20+0+0+3G,,,,M0+0+0+0+0+0+0+0+0+ : This page must bear the applicants original signature and must be dated. A copy of this form may be provided to the KY Department of Revenue. Submit this completed application and fees to the Kentucky Heritage Council upon completion of the project. 1. Property Name (if unknown, leave blank):  FORMTEXT       Street:  FORMTEXT       City:  FORMTEXT       County:  FORMTEXT       State: KY Zip:  FORMTEXT       2. Category (Check only one) 3. Project data:  FORMCHECKBOX  Owner Occupied residential property Rehabilitation costs (QRE*) $ FORMTEXT        FORMCHECKBOX  Commercial Property Total cost (QRE* plus non-QRE): $ FORMTEXT        FORMCHECKBOX  Other * Qualified rehabilitation expenditures Start date:  FORMTEXT       Completion date:  FORMTEXT       Number of housing units before / after rehabilitation:  FORMTEXT     /  FORMTEXT     Floor area before / after rehabilitation:  FORMTEXT       /  FORMTEXT       sq ft Use(s) before / after rehabilitation:  FORMTEXT       /  FORMTEXT       4. Request for Certification: I hereby apply for certification of rehabilitation work described above for purposes of the State tax incentives. I declare under penalty of law that the completed rehabilitation, to the best of my belief and knowledge, meets the "Standards for Rehabilitation" and is consistent with work described in Part 2: Historic Preservation Certification Application and any conditions issued by the Kentucky Heritage Council. Name:  FORMTEXT       (If there is more than one owner, attach full list of all owners with addresses, social security numbers or taxpayer identification numbers and percentage of ownership.) Organization:  FORMTEXT       Social Security or Taxpayer Identification Number:  FORMTEXT       (If this is a pass-through organization, such as a limited partnership, S corporation or limited liability company, attach full list of all owners.) Street:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT    Zip:  FORMTEXT       Telephone Number:  FORMTEXT       E-Mail Address:  FORMTEXT       I attest that I am the owner of the property, or am a representative authorized to sign on the behalf of the owner. Signature: ________________________________________________ Date: _______________________________________ NOTE: There is a yearly program cap that limits the total credit amount approved for all taxpayers to $5 million. The credits allocated on a preliminary approval may be adjusted to reflect actual eligible expenses. Taxpayers and the Kentucky Department of Revenue will be notified of approved final credits for completed projects. KHC Office Use Only - The Kentucky Heritage Council has reviewed this application and the Part 2-Description of Rehabilitation for this project and has determined: That the completed rehabilitation meets the Secretary of the Interiors Standards for Rehabilitation. Effective on the date indicated below, the rehabilitation of this certified historic structure is hereby designated a certified rehabilitation. This letter of certification is to be used in conjunction with appropriate Kentucky Income Tax forms.That the completed rehabilitation does not meet the Secretary of the Interiors Standards for Rehabilitation. Total Amount of Actual Eligible Expenses Reported for this ProjectTotal Pre-Approved Credit Amount Allocated for this ProjectTotal FINAL Approved Credit Amount Approved for this Project ______________________________________________________________________________ ________________________ Kentucky Heritage Council /State Historic Preservation Office Authorized Signature Date Property Name:  FORMTEXT       Property Address:  FORMTEXT       Additional Owners Continue on additional sheets as needed to list all owners. List percentage of ownership. Name:  FORMTEXT       Signature: ___________________ Date: _________ Percentage of Ownership:  FORMTEXT      Social Security or Taxpayer Identification Number:  FORMTEXT       Street:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT    Zip:  FORMTEXT       Telephone Number:  FORMTEXT       E-Mail Address:  FORMTEXT       Name:  FORMTEXT       Signature: ___________________ Date: _________ Percentage of Ownership:  FORMTEXT      Social Security or Taxpayer Identification Number:  FORMTEXT       Street:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT    Zip:  FORMTEXT       Telephone Number:  FORMTEXT       E-Mail Address:  FORMTEXT       Name:  FORMTEXT       Signature: ___________________ Date: _________ Percentage of Ownership:  FORMTEXT      Social Security or Taxpayer Identification Number:  FORMTEXT       Street:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT    Zip:  FORMTEXT       Telephone Number:  FORMTEXT       E-Mail Address:  FORMTEXT       Name:  FORMTEXT       Signature: ___________________ Date: _________ Percentage of Ownership:  FORMTEXT      Social Security or Taxpayer Identification Number:  FORMTEXT       Street:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT    Zip:  FORMTEXT       Telephone Number:  FORMTEXT       E-Mail Ad     1 2 < = 껰wpawUwEjhB>*CJOJQJUjh^>*CJUjhB>*CJU hB>*CJjhB>*CJU hn@CJhChn@CJ hn@5CJhn@5CJ\hn@hn@5CJ\aJh h#dCJaJh9 &h9]\CJaJh9]\h9]\5CJaJh+CJaJh9]\CJaJh CJaJhV h9]\CJaJhV h9]\CJaJ  r   @y dh^gdWadh^`gd dh^gdn@ dh`gd @ 0^`0gdn@0dh^`0gdn@.H$d%d&d'dNOPQ]^HgdWc    0 2 4 > @ X \ n p ѻ~te\Rhyhn@6CJhn@5CJ\jhn@>*CJUhn@5>*CJ\j\hn@>*CJUjh^>*CJUjhn@>*CJU hn@>*CJjhn@>*CJU hn@CJjh^>*CJOJQJUjhB>*CJOJQJU$jthB>*CJOJQJUhB>*CJOJQJ       6 8 : B ^ ` ƽsg[gOG<h9]\hCJaJhCJaJh9]\hn@5CJaJh%ohn@5CJaJhrhn@5CJaJ#jDhhLNhn@CJUaJhn@CJaJjhn@CJUaJ hn@CJhV hn@6CJaJ hn@6CJh9]\hn@CJaJhn@5CJ\ho5CJ\hWa5CJ\ho6CJaJhWa6CJaJhn@6CJaJhn@hn@6CJaJ @Fľ{p_VGj hn@CJUaJh>*CJaJ jh5y>*CJUaJh9]\hCJaJhCJaJh9]\hn@5CJaJhrhn@5CJaJj,hn@CJUaJhn@CJaJjhn@CJUaJ hCJ hn@CJjh^>*CJUaJ jh5y>*CJUaJh5y>*CJaJjh5y>*CJUaJ>@BZ\prt~wi^VKh9]\hWaCJaJhWaCJaJhWahWaCJaJjh^>*CJUaJ j~hWa>*CJUaJhWa>*CJaJjhWa>*CJUaJh9]\hCJaJhoCJaJ hn@CJhCJaJh hCJaJh9]\hn@CJaJhn@5CJaJh9]\hn@5CJaJhn@CJaJjhn@CJUaJDFZ\^dfnp¸¬qib¸¬Sj0hWa>*CJU h>*CJhn@CJaJjhWa>*CJUh;hn@5CJjh^>*CJUj\hWa>*CJU hWa>*CJjhWa>*CJUhChn@5CJ hn@CJh hCJaJjh^>*CJUaJjhWa>*CJUaJ jhWa>*CJUaJ 246@Btx%& +[e¸~rlf` h:iCJ hCJ hoCJhn@56CJ\]hn@hn@>*CJaJhn@5CJ\ hn@>*CJjnhWa>*CJUjhWa>*CJUhChn@5CJ hn@CJjh^>*CJUjhWa>*CJU hWa>*CJh;hn@5CJjhWa>*CJU"#&lnv|^FH\]&d P ^gdWa dh^gd^gd ^gdo^gd @ 0^`0gdn@dh^`gdWa  ,fjln$&:<>߽봨됉zj_Lj$jh>*CJOJQJUh>*CJOJQJjh>*CJOJQJUjBh>*CJU h>*CJjh>*CJUhh6CJaJhyh6CJaJh6CJaJjh^>*CJUjhB>*CJU hB>*CJjhB>*CJU hCJhhhCJaJ>HJvz  02FHJNP|ѹ஛ڏymڏ^mVhCJaJj h>*CJUjh^>*CJUj h>*CJU h>*CJjh>*CJU$j" h>*CJOJQJUh>*CJOJQJh h 6CJaJhyh6CJaJh6CJaJ hCJjh>*CJOJQJUjh^>*CJOJQJU .0DFHRTuܲܚvk]kQh9]\h9]\6CJaJh9]\h9]\5CJ\aJh9]\h9]\CJaJh9]\h#dCJaJh9]\h#d5CJ\aJhhCJaJj@ h>*CJUhJhCJj h>*CJUjh^>*CJUj` h>*CJU h>*CJjh>*CJU hCJhBhCJaJ*6<DYZ[\]psKgeg   Y [ ׹{{pi^Zi^Z^Zh lhyh lCJaJ h;^h lhyh;^CJaJhyh#d5CJ\aJhyh#dCJaJ h#dCJhyh#d5CJaJhyh#dhWahWaCJaJhCJaJhWah9]\CJaJhWah;^CJaJhWah#dCJaJh9]\h#dCJaJh9]\CJaJh9]\hPCJaJ#]efg~vkd $$Ifl0P+(064 lalyt9X$IfgdWa }}$If !vkdV $$Ifl0P+(064 lalyt9X   Y $Ifvkd $$Ifl0(P+((#064 lalyt9XY Z [ $Ifvkd $$Ifl0(P+((#064 lalyt9X !m!n!""j"l"wjjY&d P ^gdQ ^gd $ ^a$gd vkd6$$Ifl0(P+((#064 lalyt9X !Y!h!m!n!o!}!!!!!" 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Two sets of all attachments must be submitted (including photos, photo key plan, and any other additional information). It is highly recommended that the applicant make an additional copy of the forms, attachments, photo key plans and numbered photos for their own records. Checklist  please check each item to insure that a completed application is submitted. 1. Form  FORMCHECKBOX  Completed Part 3  Request for Certification of Completed Work form.  FORMCHECKBOX  Form has the applicant s original signature and must be dated.  FORMCHECKBOX  The category chosen in the part 3 application matches the category chosen in the previous part 2 application.  FORMCHECKBOX  The rehabilitation costs listed on this form match the costs on the Summary of Investment form. 2. Attachments (Summary of Investment and Election of Credit form, photographs, photo key plans)  FORMCHECKBOX  Completed Summary of Investment and Election of Credit form with applicant s original signature. Owner occupied residential projects must be notarized. All other projects must have a Certified Public Accountant complete a compilation of qualified rehabilitation expenses and sign this form.  FORMCHECKBOX  A plan of each floor of the building as it appears after rehabilitation. This plan is not required to be drawn by an architect and can be done on graph paper. Photos must be keyed to these plans. These plans should not exceed 11 x17 in size.  FORMCHECKBOX  Photos of the building as it appears after rehabilitation. Please photograph every outside face of the building and every interior room of the building (including areas where no work occurred). Please refer to the part 1 checklist for additional photo requirements.  FORMCHECKBOX  Photos have a label on the back that lists the address, approximate date the photo was taken, brief description of what is illustrated, the word  after , and a unique photo number that will be used to key it into the photo key plan(s). If possible, the numbering of the  after photos will match the  before photo numbers.  FORMCHECKBOX  Photos are on 4x6 glossy photo paper. Prints from a home printer are not acceptable.  FORMCHECKBOX  Photos are in a loose stack. They may be placed inside an envelope or have a rubber band around them. Do not submit photos inside photo albums or taped to larger sheets of paper. 3. Fee Refer to instructions and guidelines in order to determine the amount of the part 3 review fee.  FORMCHECKBOX  Check should be made out to  Kentucky State Treasurer .     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