STATE OF NEW JERSEY
ELECTION TO PARTICIPATE IN A COMPOSITE RETURN
Name of Filing Entity
Person to Contact
Type of Entity: ¨ General Partnership
¨ Limited Partnership
¨ Professional Athletic Team
¨ Estate or Trust
¨ Limited Liability Company ¨ Limited Liability Partnership ¨ NJ Electing S Corp.
Social Security Number
INDIVIDUAL CONSENT STATEMENT
By signing this election to participate, I hereby consent to have my income from the above named entity which is derived from
or connected with sources within New Jersey included on the New Jersey Nonresident Composite Return (Form NJ-1080-C). I further
consent to all provisions and requirements for such returns as contained in N.J.A.C. 18:35-5.2, including, but not limited to, the
responsibilities and liabilities of an electing participant.
I further declare that I satisfy all of the following conditions:
I was a nonresident of New Jersey for the entire year;
I did not maintain a permanent place of abode in New Jersey at any time during the taxable year;
I do not file a fiscal year tax return for federal income tax purposes;
I did not have income derived from or connected with New Jersey sources other than the income to be reported
on the composite return being filed by this or any other entity;
I waive the right to claim New Jersey personal exemptions, credits or deductions and I agree that the tax due on
my share of the composite income will be calculated at the highest tax rate in effect this year for single
I further understand that this election to participate:
Must be made annually;
Shall be binding on my heirs, representatives, assigns, successors, executors, and administrators;
May not be made after April 18, 2016; and
May not be revoked after April 18, 2016.
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.
THIS FORM MAY BE REPRODUCED