RE: ________________________
(applicant's name) |
________________________
(applicant's address) |
| The undersigned
submits the following statement of income to aid in the determination
of eligibility for a tax deduction with respect to premises located
at _____________________. |
___________________________
(municipality) |
Block No._______ Lot
No. _______ |
INCOME
FOR THE CALENDAR YEAR 19_____
(including Spouse's income) |
| 1.) Pension or Retirement
(Private) |
$__________________ |
| 2.) Salaries or Wages |
$__________________ |
| 3.) Interest and Dividends |
$__________________ |
| 4.) Net Rents or Royalties |
$__________________ |
| 5. ) Capital Gains |
$__________________ |
| 6.) Other Income |
$__________________ |
7.) Social Security Benefits
Husband_______________
Wife __________________ |
$__________________ |
8.) State or Federal
Pension, Disability Benefits
Husband_______________
Wife __________________
|
$__________________ |
9.) Railroad Retirement
Husband_______________
Wife __________________
|
$__________________ |
Annual
Gross Income
(sum of items 1 to 9 inclusive) |
$__________________ |
| NOTE: The
appropriate official will determine which of the above items are
to be excluded.) |
__________________________
(applicant's signature)
|
__________________________
(applicant's signature) |
To applicant: The above
income detail is to enable the assessor or collector to determine
which items of income may be excluded under the law and to determine
whether you meet the income requirements of the law. Failure
to complete this form may result in loss of your property tax
deduction.
State of New Jersey
Division of Taxation
Local Property & Public Utility Branch 2/75 |
