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jpSjp^Community lnvcstmcnt Tax Credit Program for the Promotion of AtTordahlc Mousing Opportunitics

CERTIFICATE OF CONTRIBUTION FOR TAX CREDIT

PART 1 - BUSINESS AND CONTRIBUTION INFORMATION (Completed by Contributor)

Name otTinancial instimtunr 1    BSEH

Business mailing address: I-—

Contact person and title:

Fiscal year from

Tennessee Franchise and Excise number: L Tax Year (Check One)    l 23 Calendar year

Type of lnvestment (Check Ali That Apply):

HQualified loan (2% below prime ratę) BQualified low-rate loan (4% below prime ratę)

■ Qualified imestment (longer than 5 years)

E Grant or contribution

Submitted by:L

By:

■I	Texl1-09	■I
■I	Tcxl1-10	■
	Toxl1-1t Texl1-12

Datę Approved

HI	Text1-13	Hi
HI	Text1-14	IH
IH	Tcx11-15	HI
■i	Tcxtt-16

Name of Financial Institution

Signature

Print Name and Title

Datę

PART 2 - ELIGIBLE HOUSING ORGANIZATION (Completed by F.ligible Organization) (Check One)

12 Tennessee Nonprofit Organization    3 Public Housing Authority

12 Development Districi    12 TH DA

...........    . i-mu-