Revised Form Promulgated by 07/01/2019 Notice to the Bar, CN 11004 page 1 of 2 NOTICE: This is a public document, which means the document as submitted will be available to the public upon request. Therefore, do not enter personal identifiers on it, such as Social Security number, driver222s license number, vehicle plate number, insurance policy number, active financial account number, or active credit card number. Tax Court of New Jersey Case Information Statement (CIS-LP) Instructions: To be attached to face of complaint (type or print) Attorney Name (List your information if you are not represented by an attorney) Attorney ID Number Street E - mail Address City State Zip Telephone Number Part A. Check one of the following case types and the filing fee Direct Appeal Added or Omitted Assessment Appeal from County Tax Board Judgment Farmland Qualification Correction of Error Farmland Rollback Exemption Other Note: In order to proceed in the Small Claims Division, the property at issue must be a class 2 property (1-4 family residence) or a class 3A farm residence or prior year222s taxes were less than $25,000. See Court Rule 8:11-(a)(2). Check for Small Claims Division Filing Fee Submitted Check/other Attorney Charge Account Number $ Part B. Fill in the following for all cases 1. Plaintiff Defendant 2. County Block Lot Unit 3. Assessment year(s) in contest 4. Property Address 5. Property Type (check one) 1 - 4 Family Residence (class 2) Business Personal Property Percentage Casino Commercial Condominium Farm Residence (class 3A) Farmland Hotel Industrial Multi - Unit Residential (over 4 Units) Nursing Home Pipeline Senior Cit izen /Vet eran Deduction Tax Exempt Vacant Land Vacant land used as part of a 1 - 4 family residence Other 6. Is plaintiff the Owner Tenant Contract Purchaser Court Appointed Rent Receiver Municipality Other American LegalNet, Inc. www.FormsWorkFlow.com Revised Form Promulgated by 07/01/2019 Notice to the Bar, CN 11004 page 2 of 2 7. Is an exemption claimed? Yes No Type If more than one assessed property is included in the complaint, are they contiguous and in common ownership? Yes No Attach individual Case Information Statements for each separately assessed parcel. If multiple condominium units, attach the Condominium/Multiple Assessment Schedule. Part C. Fill in the following for all Case Types except Farmland Rollback Assessment for the year set forth in No. 3 above Original Assessment County Tax Board Assessment Land $ Land $ Improvements $ Improvements $ Exemption $ Exemption $ Total $ Total $ Part D. Fill in the following only for Farmland Rollback Year Non - Qualified Assessed Value Qualified Assessed Value Assessment Subject to Rollback $ $ $ $ $ $ $ $ $ Part E. Fill in the following: Note: For Direct Appeals - The total assessment must be over $750,000 to qualify. The Improvement total for Part E should be the Original Improvement* and the added, omitted or omitted/added assessment for 12 months, not the prorated assessment. See Court Rule 8:2(c).) For Added Assessment ONLY Said property is the subject of an added assessment for the assessment year as follows: Original Assessment County Tax Board Judgment Improvements * $ Improvements $ Prorated Assessment $ Prorated Assessment $ for months for months For Omitted or Omitted/Added Assessment ONLY Said property is the subject of an omitted or omitted/ added assessment for the assessment year as follows: Original Assessment County Tax Board Judgment Land $ Land $ Improvements * $ Improvements $ Prorated Assessment. $ Prorated Assessment $ for months for months Do you or your client have any needs under the A mericans with Disabilities Act? Yes No If yes, please identify any requirements or accommodations you may require. Will an interpreter be needed? Yes No If yes, for what language Please Note: Only an interpreter registered with the Administrative Office of the Courts may be used during a court proceeding. I certify that confidential personal identifiers have been removed from documents now submitted to the court, and will be removed from all documents submitted in the future in accordance with Rule 1:38-7(b) Dated Signed Make Filing Fee checks payable to: Treasurer, State of New Jersey Mailing Address : Tax Court Management Office , P.O. Box 972 , Trenton, NJ 08625 - 0972 American LegalNet, Inc. www.FormsWorkFlow.com