Form Ptd - Claim For Real Property Tax Deduction On Dwelling House Of Qualified New Jersey Resident Senior Citizen, Disabled Person, Or Surviving Spouse Page 3

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S25Q REAL PROPERTY TAX DEDUCTION SUPPLEMENTAL INCOME FORM
(N.J.S.A. 54:4-8.40 etseq.; NJ.A.C. 18:14-1.1 etseq.)
,
THE BELOW INCOME DETAIL IS TO ENABLE THE COLLECTOR/ ASSESSOR TO DETERMINE WHICH ITEMS
MAY BE EXCLUDED UNDER THE LAW AND TO DETERMINE WHETHER YOU MEET THE INCOME
REQUIREMENTS OF THE LAW. THE ASSESSOR OR COLLECTOR MAY REQUEST THAT THIS INCOME
STATEMENT BE SUBSTANTIATED BY FEDERAL INCOME TAX RECORDS. FAILURE TO COMPLY MAY RESULT
IN LOSS OF YOUR SENIOR CITIZEN, DISABLED PERSON, SURVIVING SPOUSE, SURVIVING CIVIL UNION
PARTNER PROPERTY TAX DEDUCTION.
Re:
(Applicant's name)
(Address)
The undersigned submits the following statement of income to aid in the determination of eligibility for a senior
citizen, disabled person, surviving spouse, or surviving civil union partner property tax deduction with respect to premises
located at: .
_BIock
Lot
Qualifier^
(County/Municipality)
INCOME FOR THE CALENDAR YEAR
*NOTE: If married, you must include gpome'g Income
Applicant
Spouse
1. Pension or Retirement (PRIVATE)
$
$
._
2. Salary/Wages/Tips/Bonuses/Commissions
3. Interest
4. Dividends (Ordinary and Qualified)
5. IRA Distributions
6. Capital Gains
7. Business Income
8. Income from Rents/Royalties
9. Unemployment
•i
10. Alimony
11. Other income
12. Social Security Benefits
I
13. Federal Pension/Railroad Pension
14. State, County, Municipal Pension
15. Disability Benefits
Total Yearly Income (sum of items 1-15)
For Assessor/Collector Use Only
Excludable income $.
•
.
Total income after exclusion $_
I certify the above declarations arc 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.
(Applicant's signature)
(Spouse's signature)

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