$250 Real Property Tax Deduction Supplemental Income Form

PTD-SI
(Nov. 2011)
$250 REAL PROPERTY TAX DEDUCTION SUPPLEMENTAL INCOME FORM
(N.J.S.A. 54:4-8.40 et seq.; N.J.A.C. 18:14-1.1 et seq.)
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:
_________________________________Block __________________Lot________________ Qualifier_______________
(County/Municipality)
INCOME FOR THE CALENDAR YEAR___________
*NOTE: If married, you must include spouse’s income
The tax assessor/collector will determine which of the below items will be EXCLUDED.
Applicant
Spouse
1. Pension, Annuity, 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
____________________
_________________
10. Alimony
____________________
_________________
11. Other income
____________________
_________________
12. Social Security Benefits
_____________________
_________________
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 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.
_____________________________
(Applicant’s signature)
____________________________
(Spouse’s signature)