Form Bcta - Brownfields Credit Transfer Application - 2012
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1
22012
Form BCTA
Massachusetts
Brownfields Credit
Department of
Transfer Application
Revenue
For calendar year 2012 or taxable year beginning
and ending
Name of company/nonprofit organization
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:
Certificate number issued by DOR
Certificate expiration date
Amount of Brownfields credit in line 1 to be transferred with this application
Amount paid by the purchaser for the Brownfields credit
1 Brownfields credit amount eligible for transfer (amount on line 1 of Form BCC unused by the taxpayer/transferor) . . . . . . . . . . 1
Note: The taxpayer desiring to make a transfer, sale or assignment of a Brownfields credit must submit to the Commissioner a statement describing the
amount of the credit, which is eligible for such a transfer, sale or assignment. See M.G.L. Ch. 63, sec. 38Q(g) and M.G.L. Ch. 62, sec. 6(j)(5).
Name of purchasing company
Federal Identification or Social Security number
Mailing address
City/Town
State
Zip
I declare under the pains and penalties of perjury that to the best of my knowledge, the information contained herein is accurate and complete.
Signature
Title of authortized representative
Date
A copy of Form BCC must be enclosed with this application. Mail to: Massachusetts Department of Revenue, Audit Division, 200 Arlington Street,
Room 4300, Chelsea, MA 02150, attn.: Brownfields Unit.
On this
day of
, 20
, before me, the undersigned notary public, personally appeared
, provided to me through
satisfactory evidence of identification, which was
, to be the person whose name was signed above, and who swore or affirmed to me
that the private financial assistance specified in line 1 above has been provided.
Signature of notary public
Date of expiration of commission
Notary seal
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