2010
                                                                              Form BCTA                                                     Massachusetts
                                                         Brownfields Credit Department of
                                                                                                                                            Revenue
                                                         Transfer Application

For calendar year 2010 or taxable year beginning                                                                                                                    and ending
Name of company/nonprofit organization                                                 Federal Identification or Social Security number

Mailing address                                                                        City/Town                                       StateZip

Name of contact person                                                                 Telephone                                       E-mail address

Type of entity:
  Corporation  Trust      Partnership Sole proprietorshipLLC                  NonprofitOther:
Certificate number issued by DOR                                                       Certificate expiration date

Amount of Brownfields credit in line 1 to be transferred with this application

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                                       StateZip

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