Request For Certification Of Completed Work Form Page 2
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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: _________________________
Additional Owners (continued):
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_______________________________________________________________________
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_______________________________________________________________________
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_______________________________________________________________________
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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Parent category: Financial