(N.J.S.A. 54:4-8.40 et seq.; L.l963 c.l72 as amended)
IMPORTANT File this completed claim with your municipal tax assessor
or collector.
(See instructions on reverse.)
1. CLAIMANT NAME
Name(s) of claimant owner(s) permanently residing in dwelling
house.
A. { } I was a citizen of New Jersey as of October 1 of the pretax
year, i.e., the year prior
to the tax year for which deduction is claimed; and
B. { } I was also a legal or domiciliary resident of New Jersey
for at least one year
immediately prior to October 1 pretax year. See instructions
2 & 3.
A. Date of Birth
B. { } Single { } Married { } Surviving Spouse { } Legally
Separated/Divorced
A. { } I was age 65 or more years as of December 31, of the year
prior to tax year for which
deduction is claimed.
B. { } I was permanently and totally disabled and unable to be
gainfully employed as of December
31 of the year prior to the tax year. ATTACH PHYSICIAN'S
OR SOCIAL SECURITY DISABILITY
OR NEW JERSEY COMMISSION FOR BLIND CERTIFICATE.
C. { } I was a surviving spouse as of October 1 of the year prior
to the tax year and have not
remarried.
{ } I was age 55 or more as of December 31 of the year prior
to the tax year and at time of
my spouse's death. **My deceased spouse at his or her
death was receiving a { } senior
citizen's property tax deduction or a { } permanently and totally
disabled person's
property tax deduction.
Street Address Municipality
Signature of Claimant Date
2. DWELLING LOCATION
Street Address of resident owner claimant's dwelling.
(Unit # if Co-op)
County & Municipality
Block Lot / Qualifier
3. YEAR OF DEDUCTION This deduction is claimed for the tax year
(indicate tax year).
4. CITIZEN & RESIDENT (Complete A & B)
5. OWNER & OCCUPANT
{ } I (my spouse and I, as tenants by entirety), solely owned,
held title to above identified
dwelling occupied as my (our) principal or permanent residence
as of October 1 of the
pretax year. See instructions 4 & 5.
**Complete 5a only if partial owners
5a. Name of part owner % ownership interest in property
**Complete 5b only if resident-tenant shareholder in Cooperative
or Mutual Housing Corporation
5b Corporation Name of Cooperative or Mutual Housing
Co-op/M.H. Corp. Street Address Municipality
State
{ } Co-op
Net Property Tax Amount for Unit { } Mutual Housing
Corp.
6. ANNUAL INCOME LIMIT (must be reaffirmed by March 1 following
year for which deduction was given.)
{ } During the tax year for which the deduction is claimed,
I reasonably anticipate that my
annual income (and that of my spouse combined) will not
exceed $10,000 after a permitted
exclusion of Social Security Benefits, or Federal Government
Retirement/Disability Pension,
or State, County, Municipal Government and their political
subdivisions and
agencies Retirement/ Pension. See instructions 6 & 8.
7. BIRTH DATE AND MARITAL STATUS
8. SENIOR OR DISABLED CITIZEN OR SURVIVING SPOUSE (Choose A, B,
or C)
9. REAL PROPERTY TAX DEDUCTION OTHER DWELLING
I (and my spouse) did not receive a senior or
disabled citizen or surviving spouse (if applicable) property
tax deduction on another dwelling for
the same tax year except on my (our) former home identified below
where I (we) resided from
month/year to month/year.
I certify the above declarations are true to the best of my knowledge
and belief and understand they
will be considered as if made under oath and subject to penalties
for perjury if falsified.
OFFICIAL USE ONLY - Block Lot
Approved in amount of $,
{ } Age { } Disability { } Surviving Spouse of { }senior
citizen or { }disabled person
Assessor
Date
Form PTD rev. May 1996