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Form It-Hc - Certification Of Georgia Housing Tax Credit - Departments Of Revenue, Insurance And Community Affairs Page 3

IT-HC

(rev. 10/02)

the transferee, on tax returns claiming the credit should check the box indicating

transfer below. There is a three year carry forward of unused tax credits.

Name of Taxpayer ________________________________________

FEI / SS# / NAIC # of Taxpayer /Shareholder____________________

Tax Year

FYE

2001

20__

Credit Amount

Unused

Carryforward

Total Available

Credit

Georgia Tax

Liability

Current Year

Credit Allowed

Unused

Georgia

Housing Credit

Recaptured

Credit

Check if Transfer has occurred.

For Insurance Companies Only:

“I give (my) permission to the Office of the Insurance and Safety Fire Commissioner to share the

information contained herein with the Georgia Department of Revenue, Department of Community Affairs,

or other government agencies as necessary to verify and process the requested tax credit.”

Signature

Print Name

Date

Attach a copy of Page 3 and a Georgia K-1 to the Georgia State Income Tax

Return or Insurance Premium Tax Return where the credit is claimed

Form It-Hc - Certification Of Georgia Housing Tax Credit - Departments Of Revenue, Insurance And Community Affairs Page 3