CLAIM FOR REAL PROPERTY TAX DEDUCTION ON DWELLING HOUSE OF QUALIFIED NEW JERSEY RESIDENT SENIOR CITIZEN, DISABLED PERSON, OR SURVIVING SPOUSE (N.J.S.A. 54:4-8.40 et seq.; L.1963 c.172 as 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. ******************************************************************************************************** 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 { } I (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. ******************************************************************************************************** 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, or 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 31 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. { } I was age 55 or more as of December 31 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 I (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 ******************************************************************************************************** I 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 ******************************************************************************************************** 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 American LegalNet, Inc. www.FormsWorkflow.com FORM PTD GENERAL INSTRUCTIONS 1. APPLICATION FILING PERIOD - File this form with the municipal tax assessor from October 1 through December 31 of the pretax year, i.e., the year prior to the calendar tax year or with the municipal tax collector from January 1 through December 31 of the calendar tax year. For example, for a property tax deduction claimed for calendar tax year 1997, the pretax year filing period would be October 1 -