Form Rv-F130890 - Certificate Of Contribution For Tax Credit
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Community Investment Tax Credit Program for the Promotion of Affordable Housing Opportunities
CERTIFICATE OF CONTRIBUTION FOR TAX CREDIT
PART 1 - BUSINESS AND CONTRIBUTION INFORMATION (Completed by Contributor)
Name of financial institution:
Business mailing address:
Contact person and title:
Telephone number: (
)
Tennessee Franchise and Excise number:
Type of Investment (Check All That Apply):
Qualified loan (2% below prime rate) or investment
$ __________ Date Approved ________
Select Desired Credit:
(A) Five percent (5%) of the amount of the loan or investment, or
(B) Three percent (3%) annually of the unpaid principal balance of a qualified loan
Qualified low-rate loan (4% below prime rate), grant, or contribution $ __________ Date Approved ________
Select Desired Credit:
(A) Ten percent (10%) of the amount of the loan, grant, or contribution, or
(B) Five percent (5%) annually of the unpaid principal balance of a qualified low-rate loan
Submitted by:
Name of Financial Institution
By:
Signature
Date
Print Name and Title
PART 2 - ELIGIBLE HOUSING ORGANIZATION (Completed by Eligible Organization) (Check One)
Tennessee Nonprofit Organization
THDA
Community Development Financial Institution
Development District
Public Housing Authority
Name of eligible organization:
Business mailing address:
Telephone number: (
)
Contact person and title:
Type of Eligible Activity (Check All That Apply):
Activities that create or preserve affordable housing:
Construction of single family and multi-family housing
$ ____________________
Conversion
$ ____________________
Rehabilitation
$ ____________________
Acquisition
$ ____________________
Land
$ ____________________
Financing (i.e., through loan funds)
$ ____________________
Activities that help obtain housing:
Down payment assistance
$ ____________________
Pre-purchase counseling
$ ____________________
IDAs for homeownership
$ ____________________
Supportive services tied to housing (including but not limited to
services for the elderly, developmentally or mentally disabled,
youth transitioning from foster care, homeless, and other targeted
groups)
$
Deposits: Utilities and security.
$
RV-F1308901 (Rev. 11-07)
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