2010
                                                                                                                                                                                    Massachusetts
                                                       Form BCTC                                                                                                                    Department of
                                                                                                                                                                                    Revenue
                                     Brownfields Credit Transfer Certificate

For calendar year 2010 or taxable year beginning                                                                                                                                                 and ending
Name of transferee/purchaser/assignee                                            Federal Identification or Social Security number

Street address                                                                   City/Town                                       State                                              Zip

Name of transferor                                                               Federal Identification or Social Security number

Street address                                                                   City/Town                                       State                                              Zip

Address of property to which Brownfields credit relates                          City/Town                                       State                                              Zip

Certificate number issued by DOR                                                 Certificate expiration date

1Amount of Brownfields credit transferred. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Tax Return Filing
A transferee, purchaser or assignee receiving this Brownfields Credit Transfer Certificate must enter the certificate number on the appropriate line of its
Massachusetts tax return if using any part of the credit in line 1 on its return.
Department of Revenue Filing
All credit information should be mailed to: Massachusetts Department, Audit Division, 200 Arlington Street, Room 4300, Chelsea, MA 02150, attn:
Brownfields Unit.