2014
Form BCA
Massachusetts
Brownfields
Department of
Credit Application
Revenue
For calendar year 2014 or taxable year beginning
and ending
Name of applicant
Federal Identification or Social Security number
Mailing address
City/Town
State
Zip
Name of contact person
Telephone
E-mail address
Type of entity:
Corporation
Trust
Partnership
Sole proprietorship
LLC
Nonprofit
Other:
Address of property
City/Town
State
Zip
Date(s) eligible costs incurred
1 Total net response and removal costs incurred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Is the property located in an economically distressed area as defined under G.L. c. 21E and its associated regulations?
Yes
No
3 Did the Applicant own or lease the property during the remediation process?
Own
Lease
4 Date of the deed or lease for the property
5 Does the Applicant currently own or lease the property?
Yes
No. If No, date this relationship ended
6 Assessed value of the property prior to remediation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Percentage of costs with respect to the assessed value of the property prior to remediation. . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Is the Applicant an “eligible person” as defined under G.L. c. 21E, § 2?
Yes
No
9 Is the Applicant subject to any enforcement action under G.L. c. 21E?
Yes
No
10 Identify all release tracking numbers associated with this application
11 What is the outcome that has been achieved?
12 Does the permanent solution or remedy operation status include an activity and use limitation?
Yes
No
13 Date the permanent solution or remedy operation status has been achieved
14 Has the permanent solution or remedy operation status been maintained?
Yes
No
15 Did the Applicant cause or contribute to the release of oil or hazardous material from or at the site?
Yes
No
16 Did the Applicant own or operate the site at the time of the release of oil or hazardous material from or at the site?
Yes
No
17 Can any other person or entity claim the credit for the property and/or site?
Yes
No
18 Amount of the credit that Applicant is seeking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
I declare under the pains and penalties of perjury that to the best of my knowledge, the information contained herein is accurate and complete.
Name of preparer (print)
Title
Date
Signature of preparer
Mail to: Massachusetts Department of Revenue, Audit Division, 200 Arlington Street, Room 4300, Chelsea, MA 02150, attn.: Brownfields Unit.