Tennessee Certificate of Contribution For Tax Credit

Certificate of Contribution For Tax Credit
communityinvtaxcredit.pmd
RV-F1308901 (3/18)

TENNESSEE DEPARTMENT OF REVENUE
Community Investment Tax Credit Program
for the Promotion of Affordable Housing Opportunities
Certificate of Contribution for Tax Credit
Part 1 - Business and Contribution Information (completed by contributor)
Name of Financial Institution
Business Mailing Address
Contact Person and Title

Telephone Number

Name of Parent Company (if applicable)
Tennessee Franchise and Excise Number (number used when filing tax return)
Type of Investment (check all that apply):
Qualified loan (2% below prime rate) or investment

Date Approved

$

Select Desired Credit:
5% of the amount of the loan or investment, or
3% annually of the unpaid principal balance of a qualified loan
Date Approved

Qualified low-rate loan (4% below prime rate), grant, or contribution $
Select Desired Credit:
10% of the amount of the loan or investment, or
5% annually of the unpaid principal balance of a qualified loan
By

Signature

Print Name and Title

Date

Part 2 - Eligible Housing Organization (completed by eligible organization) (check one)
Tennessee Nonprofit Organization
Development District

THDA

Community Development Financial Institution
Public Housing Authority

Name of Eligible Organization
Business Mailing Address
Contact Person and Title
Type of eligible activity (check all that apply):
Activities that create or preserve affordable housing
Construction of single family and multi-family housing
Conversion
Rehabilitation
Acquisition
Land
Financing (e.g., through loan funds)
Activities that help obtain housing
Down payment assistance
Pre-purchase counseling
IDAs for homeownership
Supportive services tied to housing (including but not limited to services
for the elderly, developmentally or mentally disabled, youth transitioning
from foster care, homeless, and other targeted groups)
Deposits: Utilities and security

Telephone Number

$
$
$
$
$
$
$
$
$
$
$
$

Activities that build capacity
Operational support
Investment in technology
Training (support for nonprofits providing training or receiving training)
Technological assistance (for nonprofits who provide for or 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 affordabable housing
Research

$
$
$
$
$
$
$
$
$
$

Eligible housing organization concurrence (completed by eligible organization)
To the best of my knowledge, I agree 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 individual signing this document to criminal sanctions up to and
including a Class B Felony.

By

Signature

Print Name and Title

Date

Please include the following attachments before submitting form to Tennessee Housing Development Agency (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.

FOR OFFICE USE ONLY

Certification by THDA
Amount of eligible investment
Approved by

Signature

Print Name and Title

Date

Print Name and Title

Date

Certification by Department of Revenue
Amount of tax credit
Approved by

Signature