Form Dr 0076 - Certification Of Qualified Nature Of Enterprise Zone Rehabilitation Expenditures Page 2

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TO BE COMPLETED BY TAXPAYER, OWNER OR AUTHORIZED COMPANY OFFICIAL
Signature of Zone Administrator
Date
Enterprise Zone — See Reverse
Taxpayer/Company Name
Telephone Number
Address (street, city, ZIP)
For tax year ending
_________________________, 20 ____
Colorado Account Number (CAN)
Social Security Number or FEIN
Address of building for which expenditures were made (street, city, ZIP)
Year building was constructed
Date of last occupancy
Current year qualifying expenditures
Rehabilitation tax credit claimed
$
$
I declare that all of the above information is true and correct to the best of my knowledge and belief.
Signature of Owner/Authorized Official
Title
Date
CERTIFICATION BY ZONE ADMINISTRATOR
I
hereby certify to the Colorado Department of Revenue that the expenditure amount stated was of a nature that qualified for the
enterprise zone building rehabilitation for commercial use credit.
FOR MORE INFORMATION ABOUT ENTERPRISE ZONES CONTACT THE AGENCIES LISTED BELOW:
Colorado Department of Revenue, Denver, CO  80261–0005  Phone: 303-238-SERV(7378).
Colorado Office of Economic Development and International Trade, 1625 Broadway, Suite 2700, Denver, CO  80202  Phone: 303-892-3840.
Visit   for Enterprise Zone information,
including Enterprise Zone Administrator contact information.
12/29/11

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