4. Completed — State Historic Rehabilitation Tax Credit

a. Provide the actual start date.
- b. Provide the actual completion date.
- c. Provide the number of dwelling units before and after rehabilitation.
- d. Provide the number of low and moderate income dwelling units before and after rehabilitation.
- e. Provide the final total Qualified Rehabilitation costs (QRE).
- f. Provide the final total construction cost (QRE plus non-QRE project costs).

Completed Application category and fee:
- a. Type ‘X’ into one box for the allocation category being applied for.
- b. If ‘Qualified residence’ is selected, type ‘X’ in the box below to attest that the applicant occupies or will occupy the residence, and that the applicant’s modified adjusted gross income is $200,000 or less.
- c. The fee amounts in the boxes across from the checked allocation category are computed using the formula published in the “Application Fees and Calculation” paragraph above.
Provide Project Data required for legislative analysis:

This information must be filled out by all applicants to provide an accurate analysis. If a field does not apply to the project, write “N/A” or “none”.

a. Provide the best estimate of the number of jobs for the work skills listed on the form.
b. Estimate the state, local, and property tax increase represented by the completed rehabilitation.
c. List any other federal, state, or local incentives, grants, or other contributions that were used for the rehabilitation.
d. Select the public benefit of the rehabilitated Qualified Residence.