Khc Form Tc 3 – Fill Out and Use This PDF

Read all Instructions and Guidelines (provided separately from this application) carefully before completing this application. Type or print clearly in black ink. The decision by the Kentucky Heritage Council with respect to certification is made on the basis of the descriptions in this application form. In the event of any discrepancy between the application form and other, supplementary material submitted with it (such as architectural plans, drawings, and specifications), the application form shall take precedence. A copy of this form will be provided to the Kentucky Department of Revenue. This form must be submitted to the Kentucky Heritage Council upon completion of the project, but no later than January 30 of the year following the completion of the project and in the year the taxpayer intends to claim the credit.

Name of property: _____________________________________________________________________________________

Street: _____________________________________________________City: ______________________ State: KY Zip: _________

Data on rehabilitation project: Owner-Occupied residential property		Commercial Property/Other
Project start date: ___________________	Project Completion Date _______________________

Costs attributed solely to the rehabilitation of the historic structure: $________________________

Data on ownership and Request for Certification:

I hereby apply for certification of rehabilitation work described above for purposes of the State tax incentives. I declare under penalty of law that the information provided is, to the best of my knowledge, correct, and that in my opinion the completed rehabilitation meets the "STANDARDS FOR REHABILITATION" and is consistent with work described in Part 2:Historic Preservation Certification Application.

Name: _____________________________________________________________________________________________________

(If there is more than one owner, attach full list of all owners with addresses, social security numbers or taxpayer identification numbers.)

Organization: ______________________________________________________________________________________________

(If this is a pass-through organization, such as a limited partnership, S corporation or limited liability company, attach full list of all owners.)

Street: _______________________________________________City: _______________ State: ____ Zip: _________________

Social Security or Taxpayer Identification Number: _________________________________

Telephone Number: ______________________________________ E-Mail Address: ______________________

I attest that I have, or am the authorized representative of an entity that has, a possessory interest in the property:

Signature: ___________________________________________________________________________

Date: ______________

NOTE: The total credit amount approved for a calendar year for all taxpayers is limited to $3 million. The credits allocated on a preliminary approval may be adjusted to reflect actual eligible expenses.. Taxpayers and the Kentucky Department of Revenue will be notified of approved final credits for completed projects no later than March 30.

KHC Office Use Only - The Kentucky Heritage Council has reviewed this application and the Part 2-Description of Rehabilitation for this project and has determined:

That the completed rehabilitation meets the Secretary of the Interior’s Standards for Rehabilitation. Effective on the date indicated below, the rehabilitation of this “certified historic structure” is hereby designated a “certified rehabilitation.” This letter of certification is to be used in conjunction with appropriate Kentucky Income Tax forms.

That the completed rehabilitation does not meet the Secretary of the Interior’s Standards for Rehabilitation.

Total Amount of Actual Eligible Expenses Reported for this Project

Total Pre-Approved Credit Amount Allocated for this Project

Total FINAL Approved Credit Amount Approved for this Project

______________________________________________________________	__________________
Kentucky Heritage Council /State Historic Preservation Office Authorized Signature	Date
ڤ See Attachments

KHC Form TC-3;

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