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Form Dr 0076 - Certification Form Of Qualified Nature Of Enterprise Zone Rehabilitation Expenditures - 2009 Page 3

COLORADO DEPARTMENT OF REVENUE

DENVER CO 80261-0005

Enterprise Zone Rehabilitation Expenditures

enterprise zone administrator.

Tax year beginning date _________________________________ , 20 ________________

Colorado enterprise zone. At the time the expenditure was made, the building must have been at least 20 years old and completely

vacant for at least two years.

To claim the enterprise zone building rehabilitation credit:

Enclose a self-addressed stamped envelope.

, bills or any other docu-

QUALIFIED EXPENDITURES MEANS expenditures associated with exterior improvements, structural improvements, mechanical

improvements, or electrical improvements necessary to put the building into a proper condition for the operation of a commercial

QUALIFIED EXPENDITURES DOES NOT INCLUDE soft costs such as the cost of appraisals; architectural, engineering, and interior

bids; insurance; project signs and phones; temporary power; bid bonds; copying; and rent loss during construction. QUALIFIED

EXPENDITURES DOES NOT INCLUDE

TO BE COMPLETED BY TAXPAYER, OWNER, OR AUTHORIZED COMPANY OFFICIAL

Enterprise Zone — See Reverse

Taxpayer/Company Name

Telephone Number

(

)

Address (street, city, ZIP)

For tax year ending

____________________ , 20 _____________

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.

CERTIFICATION BY ZONE ADMINISTRATOR

, the duly authorized administrator of the designated Enterprise Zone, hereby certify to the Colorado Department of Revenue

use credit.

Signature of Zone Administrator

Date

FOR MORE INFORMATION ABOUT ENTERPRISE ZONES CONTACT THE AGENCIES LISTED BELOW:

Colorado Department of Revenue, Denver, CO 80261–0005 Phone: 303-238-SERV(7378). Refer to FYI Income 24.

Form Dr 0076 - Certification Form Of Qualified Nature Of Enterprise Zone Rehabilitation Expenditures - 2009 Page 3