Form L-9 Nr - Affidavit Form Of Non-Resident Decedent Requesting Real Property Tax Waiver(S) With Instructions Page 4
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1
2
3
4Full Assessed Value
Full Market Value
Description of New Jersey Real Estate
for Year of Death
at Date of Death
Street and Number
Municipality
County
Lot
Block
Owner(s) of Record:
(If decedent owned a fractional interest state how held and fractional value thereof).
Amount of Mortgage Balance (if any)
$
Street and Number
Municipality
County
Lot
Block
Owner(s) of Record:
(If decedent owned a fractional interest state how held and fractional value thereof).
Amount of Mortgage Balance (if any)
$
RIDERS MAY BE ATTACHED WHERE NECESSARY
Beneficiaries
Relationship to the Decedent
Interest of Beneficiary in the Estate
State Full names of all who have an interest in the Estate
(vested, contingent, operation of law, transfer, etc.)
Deponent further states the following schedule contains the names of all beneficiaries who predeceased the decedent.
Domicile at Death
Name
Date of Death
Complete and Notarize
Name _________________________________________________ Phone (
) ___________________
Mailing Address
Street _________________________________________________________________________________
To Send
City
___________________________________________ State __________ Zip ___________________
All Correspondence
State of: ____________________________________________
County of: __________________________________________
That ____________________________________________________________________________ being duly sworn, has reviewed the
information contained in this form and declares to the best of his/her knowledge it is true, correct, and complete. Deponent authorizes the
party listed above to act as the estate's representative and to receive the waiver(s) requested herein.
Subscribed and sworn before me
this _________ day of _____________________, 20______
Affidavit of:
Executor
Administrator
Joint Tenant
___________________________________________________________
_____________________________________________
(Signature of Notary Public or Attesting Officer)
Signature of Deponent
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