STATE OF NEW JERSEY - CORPORATION
FORM
NJ-1065E
ELECTION TO CONSENT TO TAXATION OR
2001
STATEMENT OF EXEMPTION
EIN
Name of Filing Entity
Mailing Address
City
State
Zip
Person to Contact
Telephone Number
Type of Entity: ¨ Limited Partnership
¨ Limited Liability Company
Federal EIN
Name of Corporation
Principal Address
City
State
Zip
CORPORATION CONSENT STATEMENT
By signing this election, the corporation hereby consents that the State of New Jersey has the right and jurisdiction to tax and
collect the corporation business tax on the corporation’s share of income from the above named entity which is derived from or
connected with sources within New Jersey.
I further agree and state that:
1. The corporation will file a corporation business tax return with the State of New Jersey and pay the appropriate tax for
the fiscal year in which the corporate partner derives income from New Jersey sources.
2. The corporation was incorporated in _________________________________ (Name of State or Jurisdiction).
3. The corporation is in good standing in the above named state or jurisdiction.
I further understand that this election to consent:
1. Must be made annually;
2. May not be made after the 15th day of the fourth month succeeding the close of the privilege period or after the return
has been filed, whichever occurs first; and
3. May not be revoked after the 15th day of the fourth month succeeding the close of the privilege period or after the return
has been filed, whichever occurs first.
By signing this statement the corporation is declaring that it is exempt from the Corporation Business Tax Act pursuant to
N.J.S.A. 54:10A-3.
Under penalties of perjury, I declare that I have examined this election, including all statements above, and to the best of my knowledge and belief,
it is true and correct and that I am properly authorized to sign and make this consent on behalf of :
_______________________________________________________________________________________________________________________
Name of Corporation
__________________________________________________________________________
______________________________________
Signature of Corporate Officer and Title
Date
THIS FORM MAY BE REPRODUCED