Form Rv-F130890 - Certificate Of Contribution For Tax Credit Page 2
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2Activities that build capacity:
Operational support
$ ____________________
Investment in technology
$ ____________________
Training (support for nonprofits providing training or
receiving training)
$ ____________________
Technical assistance (for nonprofits who provide or to fund
those who need assistance)
$ ____________________
Other activities:
Emergency mortgage assistance
$ ____________________
Home improvements for handling accessibility
$ ____________________
Activities to help maintain housing and prevent homelessness
$ ____________________
Post-purchase, foreclosure prevention counseling
$ ____________________
Activities to promote public awareness about affordable housing
$ ____________________
Research
$ ____________________
ELIGIBLE HOUSING ORGANIZATION CONCURRENCE (Completed by Eligible Organization)
To the best of my knowledge, I endorse that the information contained in this form is true and
correct and that the document has been fully authorized by the governing body of the eligible
housing organization. I will comply with the program rules and regulations if certification is
granted. I also confirm that I am aware that providing false information can subject the indi-
vidual signing this document to criminal sanctions up to and including a Class B Felony.
Submitted by:
Name of Eligible Housing Organization
By:
Signature
Print Name and Title
Date
Please include the following attachments before submitting form to THDA:
(1) COPY OF 501(C)(3) DESIGNATION LETTER FROM THE IRS.
(2) Tennessee Nonprofit Organizations must attach a copy of a Certificate of Existence from the Tennessee
Secretary of State’s Office dated no more than 12 months prior to the date of application submission.
(3) Briefly describe your proposed activity. Tell what you are going to do, where you are going to do it,
who and how many will benefit, the income levels of the population to be served, how you will use the
funds from the financial institution, and the expected timeframe for completion.
PART 3 - THDA CERTIFICATION (Completed by THDA)
Amount of Eligible Investment:
Approved by:
Signature
Print Name and Title
Date
PART 4 - DEPARTMENT OF REVENUE CERTIFICATION (Completed by Revenue)
Amount of Tax Credit:
Approved by:
Signature
Print Name and Title
Date
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