DCEO Office Use Only

Rev. 12/11 ILLINOIS DEPARTMENT OF COMMERCE AND ECONOMIC OPPORTUNITY & THE ILLINOIS HISTORIC PRESERVATION AGENCY ILLINOIS HISTORIC PRESERVATION TAX INCENTIVE PROGRAM CERTIFICATION OF QUALIFIED EXPENDITURES PART C DCEO/IHPA PROJECT NUMBER FEDERAL PROJECT NUMBER

Read all instructions carefully before completing the application. No certifications will be made unless a completed application form has been received. Type or print clearly in black ink. If additional space is needed, use continuation sheets or attach blank sheets. The applicant submits this PART C form only after receiving the certified PART 3 (Request for Certification of Completed Work) of the Federal Historic Preservation Certification Application (FHPCA) from the National Park Service. The FHPCA is downloadable from http://www.illinoishistory.gov/PS/taxcredits.htm. 1. Name of property ______Street City County State Zip 2. Project contact (if different from Owner) Name Street ______City ______State Zip Phone Email 3. Owner I hereby attest that all information contained in this application, including the documentation, is true to the best of my knowledge and belief. I am granting the State of Illinois access to material, documentation and other data required to verify application information. The owner certifies that it is an individual or company that is in good standing and has no delinquent tax liabilities. Name ______Signature ______Date Organization Email Street ______City State Zip Phone 4. Expenditures incurred Total of qualified expenses (those attributed solely to the rehabilitation of the $ historic structure) Please attach a summary and all supporting documentation (proof) of the qualified expenditures incurred. Total of non-qualified expenses (those attributed to new construction, new $ additions, site work, parking lots, landscaping, etc.) Please attach a summary and all supporting documentation (proof) of the non-qualified expenditures incurred. 5. Purchase price of the historic structure Owner’s purchase price for this historic structure $ Please attach supporting documentation that displays the purchase agreement and ownership interest for the historic structure. DCEO office use only Illinois Department of Commerce and Economic Opportunity has reviewed and officially certifies this “Certification of Qualified Expenditures – PART C” for the above-named project, owner, qualified expenditures, and purchase price of the historic structure.

Date DCEO Authorized Signature DCEO Contact Phone #