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Form It-Hc - Certification Of Georgia Housing Tax Credit - Departments Of Revenue, Insurance And Community Affairs

STATE OF GEORGIA

Departments of Revenue, Insurance and Community Affairs

Certification of Georgia Housing Tax Credit

This Section to be

completed by DCA

IT-HC (rev. 10/02)

Part lA. Credit

1. Building Address

2. Building Owner and Address

3. Building Owner TIN

4. Federal Building Identification Number

5. Maximum Allowable GHTC Amount

6. Date Building Placed in Service

Signature of Authorized DCA Official

Date

Part IB. Owner Certification

Ownership Entity

Under penalties of perjury, I declare that: (1) the above building continues to qualify as a part of a

qualified low-income housing development and meets the requirements of Internal Revenue Code

Section 42 (g) and O.C.G.A. Section 48-7-29.6 and (2) the qualified basis of the building (check one)

_____has _____has not decreased for this tax year. I have examined this form, and to the best of my

knowledge and belief, it is true, correct and complete.

Signature

Taxpayer ID Number

Date

Name (please type or print)

TIN refers to Taxpayer identification number.

Form It-Hc - Certification Of Georgia Housing Tax Credit - Departments Of Revenue, Insurance And Community Affairs