Form Gtb-10 - Application For Tax Clearance - Business Assistance And Incentives Form - New Jersey Division Of Taxation

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State of New Jersey
Division of Taxation
Business Assistance Clearance Section
th
50 Barrack Street – 9
Floor
P.O. Box 272
Trenton, NJ 08695-0272
APPLICATION FOR TAX CLEARANCE – BUSINESS ASSISTANCE AND INCENTIVES
Application Fee Required
Standard processing $75.00
Expedited processing (a response within 3 business days) $200.00
Legal Name of Applicant ________________________________________________________________
Trade Name of Applicant _______________________________________________________________
Business Location Address______________________________________________________________
____________________________________________________________________________________
Mailing Address for Clearance Certificate (If different from Business Location Address)
____________________________________________________________________________________
____________________________________________________________________________________
NJ Tax Registration # ___________________________ FID/TIN # ______________________________
__________________________________________________________
Type of Business
List All Officers or Partners on page 2 of application.
Please list on page 2 of this application any parent company, subsidiary or other related entity that will
directly benefit from this assistance.
====================================================================================================
Name of Issuer State Agency ________________________________Due Date___________________
Name of Assistance Program________________________________ Application# ________________
Agency Contact Person ________________________________________________________________
Agency Contact Address _______________________________________________________________
Agency Contact Phone # ____________________ Agency Contact Fax # ________________________
Agency Contact Email _________________________________________________________________
I certify that I am autho rized to complete this tax clearance application; that it is true and complete; and
that if any informatio n contained in this tax clearan ce application is willfully false, I may be subje ct to
penalty.
I understand that the Division of Taxation may communicate to the issuer Stat e agency, the status of th e
tax compliance of the applicant. By signing this tax clearance application, I consent to the release of such
general status information by the Division of Taxation.
______________________________________
____________________________
___________
Signature of Authorized Representative
Title
Date
________________________________________________
________________________________________* Required*
Print Name
Contact
Phone Number
Gtb-10 (R5 – 10/10)
Page 1

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