2009
                                                                                                                                                                                                    Massachusetts
                            Individual Certificate HRC                                                                                                                                              Department of
                                                                                                                                                                                                    Revenue
                            Historic Rehabilitation Credit

For calendar year 2009 or taxable year beginningand ending
Name of recipient                          Social Security or Federal Identification number

Street address                             City/Town                                                                State                                                                           Zip

Name of project                            Building identification number

Street address                             City/Town                                                                State                                                                           Zip

Name of project owner                      Federal Identification number

Street address                             City/Town                                                                State                                                                           Zip

Certificate Number
Certificate number issued by Massachusetts Historical Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Allotment Amount
Amount of allotted credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Distribution to Partners, Members or Owners
The owner of a project that is eligible to claim the Historic Rehabilitation Credit issues this Individual Certificate HRC. If the owner of the project distributes
or assigns any portion of the credit to its partners, members or owners, the project or owner must complete an Allotment HRC Historic Rehabilitation Credit
Summary. In addition, the project or owner must fill out and provide to each such partner, member or owner, an Individual Certificate HRC, Historic Rehabil-
itation Credit, indicating the amount of the individual credit distributed or assigned.
Tax Return Filing
Partners, members or owners receiving an Individual Certificate HRC, must file copies of such certificate and copies of the attendant Project Certificate and
Allotment HRC Historic Rehabilitation Credit Summary with their Massachusetts tax return.
Department of Revenue Filing
The project or owner must file a copy of the Project Certificate issued by the Massachusetts Historical Commission, and copies of both the Allotment HRC
Historic Rehabilitation Credit Summary and the Individual Certificate HRC, with the Department of Revenue. Mail to: Massachusetts Department of Rev-
enue, 200 Arlington Street, Room 4300, Chelsea, MA 02150, Attn.: Historic Rehabilitation Unit.