of low-moderate income dwelling units before/after rehabilitation:

Total construction cost (QRE+nonQRE) Final rehabilitation cost (QRE):

5. Application category and fee

Select one: Final Total fee: Due with Completed Apppleted Appleted Apppplication: Qualified residence I attest that I own and occupy, or will occupy within two years, the subject qualified residence, and that my modified adjusted gross income is $200,000 or less. Qualified rehabilitation expenditure under $1,000,000

Final Total fee: Due with Completed Apppleted Appleted Apppplication:

Qualified rehabilitation expenditure $1,000,000 or more

6. Data required for legislative analysis

All fields must be filled out. If a field does not apply, indicate "0".

1. Estimate the number of jobs contributing to the project:

2. Estimate the state, local and property tax increase represented by the completed rehabilitation:

   • State tax:

Local tax: Property tax:

3. List any additional incentives, grants or contributions by federal, state or local governments used for the rehabilitation by source and dollar amount. If more space is needed, continue on a second page.

4. Select the public benefit of the rehabilitated Qualified Residence:

   • The residence is associated with a major event The residence embodies distinctive characteristics The residence yields or may yield information. The residence is associated with a significant perso

The residence is a contributor to a historic district associated with one or more of the criteria above.