Fillable STATE TAX CREDIT REHABILITATION CERTIFICATION APPLICATION COVER SHEET

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STATE TAX CREDIT REHABILITATION CERTIFICATION APPLICATION COVER SHEET

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STATE TAX CREDIT REHABILITATION CERTIFICATION APPLICATION
COVER SHEET
(TO BE SUBMITTED WITH PART 2)
I certify that I have read the State Rehabilitation Tax Credit Instructions. I understand that my project scope of work
must comply with the Secretary of the Interior’s Standards of Rehabilitation and that the State Historic Preservation
Office must approve all proposed work before physical work begins.
Signature of Owner date
Signature of Project Contact date
Please submit this form to the Kansas State Historical Society with your Part 2 form.
Refer to the Application Instructions for an explanation of and help with these forms.
Kansas Rehabilitation Tax Credit Application
Description of Rehabilitation
Part 2
STC Project Number:
Please read the instructions carefully before completing this application. Applications must be complete and submitted to KSHS for approval
before certification can be awarded. Type or print clearly. If additional space is needed, use continuation sheets or attach blank sheets. Be sure
to include photos or documentation as requested in the application instructions.
Property Name:
Street:
City: County: Zip Code:
Building Information:
Date of Construction: Primary Historic Materials:
Historic Use of Building: New/Current Use of Building:
Proposed Start Date: Proposed Completion Date:
Estimated Project Total: Amount of Grant Funds, Insurance Money:
Floor area before/after Rehabilitation: /
Project Contact:
Name:
Street: City: State: Zip:
Phone: Email:
Owner Information
Legal Property Owner(s):
Type of Ownership Entity (check one):
□ Individual □ Corporation □ LLC/LP* □ Bank □ Insurance □ Non-Profit
□ Government □ School Dist. □ University □ Fiduciary □ Other
Owner’s Tax ID Number: SSN or FEIN (circle one)
Street Address: City: State: Zip:
Daytime Phone: Email:
Signature of Owner: Date:
*All Pass-Through entities must fill out the Additional Owners form providing ownership information for each shareholder within the entity.
State Office Use Only:
The State Historic Preservation Office has reviewed the Part 2 Application for the above-named property and determines that the rehabilitation:
□ The rehabilitation described meets the Secretary of the Interior’s Standards for Rehabilitation.
□ The rehabilitation described does not meet the Secretary of the Interior’s Standards for Rehabilitation.
□ The rehabilitation will meet the Secretary of the Interior’s Standards for Rehabilitation if the attached conditions are met.
Date:
SHPO/Deputy SHPO
Signature:
State Rehabilitation Tax Credit Application
Additional Ownership Form
If the ownership entity for the property undergoing rehabilitation is a pass through entity or comprised of multiple owners, please fill out
the following form to identify the shareholders, partners or members and additional owners. In the case of an LLC, any Tax Credit
Certificates will be issued to the pass through entity, but any partners, shareholders, members or owners, who may be utilizing the credits,
must be identified in order to have access to their portion of the credits. In the case of multiple owners with no organized entity, please list
each owner and their ownership percentage; credits will be awarded to each property owner based upon their percentage. Please include
an entry for each owner, partner, shareholder or members within the ownership or ownership entity (duplicate form as needed).
Property Name:
Legal Property Owner(s):
Name of Partner/Shareholder/Additional Owner:
Type of Entity:
□ Individual □ Corporation □ LLC/LP □ Bank □ Insurance □ Non-Profit
□ Government □ School Dist. □ University □ Fiduciary □ Other
Tax ID Number: SSN or FEIN (circle one) Ownership Percentage:
Street Address: City: State: Zip:
Daytime Phone: Email:
Name of Partner/Shareholder/Additional Owner:
Type of Entity:
□ Individual □ Corporation □ LLC/LP □ Bank □ Insurance □ Non-Profit
□ Government □ School Dist. □ University □ Fiduciary □ Other
Tax ID Number:
SSN or FEIN (circle one) Ownership Percentage:
Street Address: City: State: Zip:
Daytime Phone: Email:
Name of Partner/Shareholder/Additional Owner:
Type of Entity:
□ Individual □ Corporation □ LLC/LP □ Bank □ Insurance □ Non-Profit
□ Government □ School Dist. □ University □ Fiduciary □ Other
Tax ID Number: SSN or FEIN (circle one) Ownership Percentage:
Street Address: City: State: Zip:
Daytime Phone: Email:
PART 2 – SCOPE OF WORK
Property Name:
In the sections provided, describe the proposed rehabilitation project. Be sure to include all work being done to the
property and specific details about the work to be performed. Please attach additional sheets as necessary.
NUMBER
1
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
NUMBER
2
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
PART 2 – SCOPE OF WORK
Property Name:
NUMBER
3
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
NUMBER
4
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
PART 2 – SCOPE OF WORK
Property Name:
NUMBER
5
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
NUMBER
6
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
PART 2 – SCOPE OF WORK
Property Name:
NUMBER
7
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
NUMBER
8
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
PART 2 – SCOPE OF WORK
Property Name:
NUMBER
9
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
NUMBER
10
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
PART 2 – SCOPE OF WORK
Property Name:
NUMBER
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
NUMBER
Architectural Feature:
Principal Material of
Feature:
Approx. Date of Feature:
Location of Feature:
Describe existing feature and its current condition:
Photo no.
Drawing no.
Describe proposed work on feature (include methods, materials, specifics):
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STATE TAX CREDIT REHABILITATION CERTIFICATION APPLICATION COVER SHEET

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Completed 30 March 2022

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