Initial Statement Of Organization Claiming Property Tax Exemption Form
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2INITIAL STATEMENT OF ORGANIZATION CLAIMING PROPERTY TAX EXEMPTION
(N.J.S.A.54:4-4.4; & 54:4-3.5; 54:4-3.6; 54:4-3.6a; 54:4-3.9; 54:4-3.10; 54:4-3.13; 54:4-3.15; 54:4-3.24; 54:4-3.25;
54:4-3.26; 54:4-3.27; 54:4-3.35; 54:4-3.52; 54:4-3.64; & N.J.S.A.8A:5-10 et al)
IMPORTANT File this claim in duplicate with municipal assessor of taxing district where property is located by
November 1 of the pretax year. Separate claims must be filed for each parcel. Every third year as of November 1 a
Further Statement updating the organization’s status must be filed with the assessor. See instructions.
1. CLAIMANT ORGANIZATION NAME
__________________________________________________________________________________________________
2. ORGANIZATION ADDRESS (Corporate Headquarters)
__________________________________________________________________________________________________
3. CONTACT INDIVIDUAL, REPRESENTATIVE, OFFICER for ORGANIZATION
__________________________________________________________________________________________________
Name
Phone #
E-Mail Address
Fax #
__________________________________________________________________________________________________
Postal Mailing Address
__________________________________________________________________________________________________
4. INCORPORATION
A. Domestic-Incorporated or organized in New Jersey on (month/day/year) _________under statute cite #_____________
B. Foreign-Incorporated or organized in the state of ______________ on (month/day/year) ________________________
Registered with New Jersey Secretary of State on (month/day/year) ___________________________________________
5. ORGANIZATION’S PURPOSES (Explain organization’s purposes. Attach Certificate of Incorporation, Articles of
Association, Charter/Mission Statement, and Constitution & By-laws.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
6. NEW JERSEY STATUTE UNDER WHICH PROPERTY TAX EXEMPTION IS CLAIMED
State New Jersey statute cite # and brief description (see list in instructions)
__________________________________________________________________________________________________
7. PROPERTY LOCATION IN NEW JERSEY
__________________________________________________________________________________________________
Street Address
City
Zip Code
__________________________________________________________________________________________________
County
Municipality
Block #
Lot #
Qualifier
8. PROPERTY OWNERSHIP
Grantor (Seller) _______________________________ Grantee (Buyer) _______________________________________
Deed Date (Month/Day/Year) ____________________ Deed Book _________________
Page _______________
County of recording ____________________________ Recording Date _______________________________________
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Owner of legal title
Yes
No
If no, describe ownership arrangement. Attach ownership document.
__________________________________________________________________________________________________
9. PROPERTY’S PHYSICAL DESCRIPTION
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Total Land Area (Sq. Ft./Acreage) _____ Land is
Vacant or
Improved with buildings and/or structures? (Check one)
If improved, state number of buildings and/or structures ____________________________________________________
State each building size in square feet ___________________________________________________________________
Fully describe each building/structure type _______________________________________________________________
State $ amount for which improvements are insured __________________
10. PROPERTY’S ACTUAL USE or ACTUAL/EXCLUSIVE USE
If vacant land, state uses and area size for each use. If not used, state none. _____________________________________
If improved with buildings and/or structures, state uses of each. ______________________________________________
__________________________________________________________________________________________________
Are land and/or buildings used for stated purposes of claimant organization per section 5 above?
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No
Yes If yes,
Entirely or
Partially? Explain if used for other than claimant organization’s purposes or if used
or occupied by other than the claimant organization ____________________________________________________
__________________________________________________________________________________________________
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Are land and/or buildings leased or rented by other than claimant organization?
No
Yes
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If yes,
Entirely or
Partially? Percentage of property leased ____%
Attach copy lease/rental agreement.
Explain rental uses. _________________________________________________________________________________
State tenant names and rental income received.
__________________________________________________________________________________________________
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Is commercial business conducted on premises?
No
Yes If yes, explain __________________________________
11. COMPENSATION, REMUNERATION RECEIVED
List names of individuals, officers, entities receiving compensation, salaries, allowance, monetary profits from claimant
organization and dollar amounts received. If none, state none. Supporting financial data may be required by assessor.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
12. SIGNATURE, DATE & TITLE OF OFFICER CLAIMING EXEMPTION FOR ORGANIZATION
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.
Signature________________________________ Official Title or Position ______________________Date__________
__________________________________________________________________________________________________
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Official Use
Denied
Approved
Exempt Property Code_____________________________
Assessor______________________________________________________________________Date_________________
Form I.S. Rev. December 2001. This form is prescribed by the Director, Division of Taxation, as required by law, and
may not be altered without the approval of the Director.
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