Form Hr-1040-X - Amended Homestead Rebate Application - 2003
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1
2STATE OF NEW JERSEY
HR-1040-X
AMENDED
2003
HOMESTEAD REBATE APPLICATION 2003
Please Print or Type
You must enter your social security number below
Your Social Security Number
Last Name, First Name and Initial
(Joint filers enter first name and initial of each - Enter spouse last name ONLY if different)
Spouse’s Social Security Number
Home Address (Number and Street, including apartment number or rural route)
County/Municipality Code
City, Town, Post Office
State
Zip Code
1.
Single
RESIDENCY STATUS
2.
Married, filing joint return
From________________________________
6. If you were a New Jersey resident for
3.
Married, filing separate return
Month
Day
Year
ONLY part of the taxable year, give the
4.
Head of household
period of New Jersey residency:
To___________________________________
5.
Qualifying widow(er)
Month
Day
Year
7. On December 31, 2003, I (and/or my spouse) was
Age 65 or older
Blind or disabled
Not 65 or blind or disabled
Check only one box. See instructions page 2
8. Enter the GROSS INCOME you reported on Line 29, Form NJ-1040 or see instructions . . . . . . . . . . . . . . . . . .
8
9. If your filing status is MARRIED, FILING SEPARATE RETURN and you and your spouse
MAINTAIN THE SAME PRINCIPAL RESIDENCE, enter the gross income reported on your spouse’s
return (Line 29 Form NJ-1040) and check this box
. . . . . . . . . . . . . . . . . . . .
9
10. TOTAL GROSS INCOME (Add Line 8 and Line 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
STOP - IF LINE 10 IS MORE THAN $100,000, YOU ARE NOT ELIGIBLE FOR A REBATE. FURTHER RESTRICTIONS MAY BE APPLIED.
11. Enter your New Jersey residence on December 31, 2003, if different than above. If you were not a resident on December 31, 2003, enter your last
New Jersey residence.
Street Address ____________________________________________________________ Municipality __________________________________
12. Check your residency status during 2003:
a.
HOMEOWNER
b.
TENANT
c.
BOTH
13. If you checked “Homeowner” or “Both” on Line 12, enter
14a. Did you live at more than one New Jersey residence
the block and lot number of the residence for which the
during the year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
rebate is claimed.
b. Did you share ownership of a principal residence during
the year with anyone other than your spouse? . . . . . . . . . .
Yes
No
c. Did any principal residence you owned during the year
Block ___________________________
consist of multiple units? . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Lot _____________________________
d. Did anyone, other than your spouse, occupy and share
rent with you for an apartment or other rental dwelling
Qualifier _________________________
during the year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If you answered “Yes” to any of the above, you MUST complete Schedule HR-A.
HOMEOWNER
15. Enter the total 2003 property taxes you (and your spouse) paid on your
principal residence in New Jersey during 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
IF YOU COMPLETED SCHEDULE HR-A, Part I, enter:
16a. Total Property taxes paid (Sch. HR-A, PART I, Line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16a
16b. Number of days as an owner (Sch. HR-A, PART I, Line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16b
Days
TENANT
17. Enter the total rent you (and your spouse) paid on your principal residence in New Jersey during 2003 . . . . . .
17
IF YOU COMPLETED SCHEDULE HR-A, Part II, enter:
18a. Total Rent Paid (Sch. HR-A, PART II, Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18a
18b. Number of days as a tenant (Sch. HR-A, PART II, Line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18b
Days
Under the penalties of perjury, I declare that I have examined this homestead rebate application, including accompanying schedules and
statements, and to the best of my knowledge and belief, it is true, correct, and complete. If prepared by a person other than taxpayer,
this declaration is based on all information of which the preparer has any knowledge.
Mail application to:
___________________________________________________________________________________________________________
NJ Division of Taxation
Your Signature
Date
Spouse’s Signature (if filing jointly, BOTH must sign)
PO Box 253
Paid Preparer’s Signature
Federal Identification Number
Trenton, NJ 08695-0253
Firm’s Name
Federal Employer Identification Number
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