Tax Credit Certification Application Form - Georgia Department Of Natural Resources

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GA DNR Tax Credit Certification Application
GEORGIA CONSERVATION TAX
CREDIT PROGRAM
Georgia Department of Natural Resources
Wildlife Resources Division
2065 U.S. Highway 278 S.E.
Social Circle, GA 30025-4743
(770) 918-6411
APPLICATION FOR: __PRE-CERTIFICATION OR
__CERTIFICATION
(check one)
for CERTIFICATION, was this pre-certified? ___yes ___no
PROTECTION TYPE: __FEE-SIMPLE OR __CONSERVATION EASEMENT (check one)
Landowner/Donor Information
Landowner/Donor
Mailing Address
City
Zip
Phone #(s)
Email
Contact Person (if different from above)
Contact Name
Organization / Title
Mailing Address
City
Zip
Phone #(s)
Email
Please indicate where to send response letter: __Landowner or __Contact Person
Fee-simple Recipient or Easement Holder
Recipient
Contact Name/Title
Mailing Address
City
Zip
Phone #(s)
Email
Currently certified as a Qualified Organization by DNR?**
Yes _____ No _____
Not Applicable (Federal, state or local government entity) _____
Page 1 of 7
Revised January 2013

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