Form Ptr Income Report - Property Tax Reimbursement - 2013
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1PTR
STATE OF NEW JERSEY
INCOME REPORT
2013 PROPERTY TAX REIMBURSEMENT
Social Security Number:
-
-
Spouse’s/CU Partner’s Social Security Number:
-
-
________________________
_______________________
Name: ___________________________________________________________________________________________
Last Name, First Name and Initial (Joint filers enter first name and initial of each. Enter Spouse’s/CU Partner’s last name ONLY if different.)
DETERMINING INCOME
See the instructions for information on possible sources of income and how to determine the amount to be reported in each category. If
you had no income in a particular category, leave that line blank. Losses in one category of income cannot be used to reduce total income.
If you have a net loss in any income category, leave that line blank. If you were married or in a civil union as of December 31,
and living in the same household, combine your incomes for that year. If you lived in separate households, file as “single.”
INCOME CATEGORIES
2012
2013
a. Social Security Benefits (including Medicare
Part B premiums) paid to or on behalf of
applicant. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Pension and Retirement Benefits (including
IRA and annuity income) See instructions for
calculating amount. . . . . . . . . . . . . . . . . . . . .
c. Salaries, Wages, Bonuses, Commissions, and
Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. Unemployment Benefits . . . . . . . . . . . . . . . . .
e. Disability Benefits, whether public or private
(including veterans’ and black lung benefits). .
f. Interest (taxable and exempt). . . . . . . . . . . . .
g. Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . .
h. Capital Gains . . . . . . . . . . . . . . . . . . . . . . . .
i. Net Rental Income . . . . . . . . . . . . . . . . . . . .
j. Net Profits From Business . . . . . . . . . . . . . . .
k. Net Distributive Share of Partnership Income .
l. Net Pro Rata Share of S Corporation Income .
m. Support Payments . . . . . . . . . . . . . . . . . . . . .
n. Inheritances, Bequests, and Death Benefits . .
o. Royalties . . . . . . . . . . . . . . . . . . . . . . . . . . . .
p. Gambling and Lottery Winnings
(including New Jersey Lottery) . . . . . . . . . . . .
q. All Other Income . . . . . . . . . . . . . . . . . . . . . .
,
.
Total 2012 Income (Add lines a-q above)
,
.
Total 2013 Income (Add lines a-q above)
2013 INCOME ELIGIBILITY
2012 INCOME ELIGIBILITY
Total annual income cannot
Was your total 2012 income
Was your total 2013 income
exceed amounts shown.
$82,880* or less?
$84,289* or less?
Yes. See 2013 income eligibility.
Yes. You met 2013 income limit.
No. STOP. You are not eligible
No. STOP. You are not eligible
for the reimbursement and you
for the reimbursement and you
should not file this application.
should not file this application.
*Subject to change by State Budget.
*Subject to change by State Budget.
PTR Income Report
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