Form Ptd - Claim For Real Property Tax Deduction On Dwelling House Of Qualified New Jersey Resident Senior Citizen, Disabled Person, Or Surviving Spouse
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4CLAIM FOR REAL PROPERTY TAX DEDUCTION ON DWELLING HOUSE OF QUALIFIED NEW JERSEY
RESIDENT SENIOR CITIZEN, DISABLED PERSON, OR SURVIVING SPOUSE
fNJ.S.A. 54:4-8.40 et scq.: L.1963 c.t72 »s amended)
IMPORTANT File this completed claim with your municipal tax assessor or collector. (See instructions on reverse.)
1. CLAIMANT NAME
Name(s) of claimant owner(s) permanently residing in dwelling house.
*«**«**4nMi««**************###*#*^****#4nl^*****4^*^*****##*##*******«****^**#4MM#4i*4(*#*********4i****4i^*4i*
2. DWELLING LOCATION
Street Address of resident owner claimant's dwelling.
(Unit # if Co-op)
County & Municipality
Block / Lot / Qualifier
3. YEAR OF DEDUCTION This deduction is claimed for the tax year
(indicate tax year).
4. CITIZEN & RESIDENT (Complete A & B)
A. { } I was a citizen of New Jersey as of October 1 of the pretax year, i.e., the year prior to the tax year for which
deduction is claimed; and
B. { } I was also a legal or domiciliary resident of New Jersey for at least one year immediately prior to October 1
pretax year. See instructions 2 & 3.
5. OWNER & OCCUPANT
{ } 1 (my spouse and I, as tenants by entirety), solely owned, held title to above identified dwelling occupied as my (our)
principal or permanent residence as of October 1 of the pretax year. See instructions 4 & 5.
**Complete 5a only if partial owners
5a. Name of part owner
% ownership interest in property
**Complete 5b only if resident-tenant shareholder in Cooperative or Mutual Housing Corporation
5b. Corporation Name of Cooperative or Mutual Housing
Co-op/M.H. Corp. Street Address
Municipality
State
$
{ } Co-op
Net Property Tax Amount for Unit
{ } Mutual Housing Corp.
^i****************************************************************************^*^^*^^^^*******^*
6. ANNUAL INCOME LIMIT (must be reaffirmed by March 1 following year for which deduction was given.)
{ } During the tax year for which the deduction is claimed, I reasonably anticipate that my annual income (and that of my
spouse combined) will not exceed $ 10,000 after a permitted exclusion of Social Security Benefits, or Federal Government
Retirement/Disability Pension, fir State, County, Municipal Government and their political subdivisions and agencies
Retirement/Disability Pension. See instructions 6 & 8.
7. BIRTH DATE AND MARITAL STATUS
A. Date of Birth
B. { } Single
{ } Married
{ } Surviving Spouse
{ } Legally Separated/Divorced
8. SENIOR OR DISABLED CITIZEN OR SURVIVING SPOUSE (Choose A, B, or C)
A. { } I was age 65 or more years as of December 31, of the year prior to tax year for which deduction is claimed.
B. { } I was permanently and totally disabled and unable to be gainfully employed as of December 3 1 of the year prior to
the tax year,- ATTACH PHYSICIAN'S OR SOCIAL SECURITY DISABILITY OR NEW JERSEY COMMISSION FOR
BLIND CERTIFICATE.
C. { } I was a surviving spouse as of October 1 of the year prior to the tax year and have not remarried. { } 1 was age 55
or more as of December 3 1 of the year prior to the tax year and at time of my spouse's death. **My deceased spouse at his or
her death was receiving a { } senior citizen's property tax deduction or a { } permanently and totally disabled person's
property tax deduction.
9. REAL PROPERTY TAX DEDUCTION OTHER DWELLING 1 (and my spouse) did not receive a senior or disabled citizen
or surviving spouse (if applicable) property tax deduction on another dwelling for the same tax year except on my (our) former home
identified below where I (we) resided from _
month/year to _
month/year.
Street Address
Municipality
1 certify the above declarations are true to the best of my knowledge and belief and understand they will be considered as if made under
oath and subject to penalties for perjury if falsified.
Signature of Claimant
Date
if %>f **** i((##*##if *#+l4t*#^t+*^****#####**#***#**+#+#*+#***#*******##** + ***#+***+***#+***+*+*******************
OFFICIAL USE ONLY - Block
__
Lot _
Approved in amount of $
_
{ } Age
{ } Disability
{ } Surviving Spouse of { } senior citizen or { } disabled person
Assessor __ ___ ___ _
Date
_
Form PTD rev. May 1996
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