Form Ptr-1 - Property Tax Reimbursement Application - 2014 Page 2
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3PTR-1 (2014) Page 2
Name(s) as shown on PTR-1
Your Social Security Number
DETERMINING TOTAL INCOME: LINES 7 and 8: Enter your annual income for 2013 and 2014. See “Income Standards” and
“Determining Total Income” in the instructions for information on possible sources of income and how to determine the amount to be
reported in each category. If you had no income in a particular category, leave that line blank. Losses in one category of income cannot
be used to reduce total income. If you have a net loss in any income category, leave that line blank. If you were married or in a
civil union as of December 31 of either 2013 or 2014, and living in the same household, combine your incomes for that year. If you lived
in separate households, file as “single.”
INCOME CATEGORIES
2013
2014
a. Social Security Benefits (including Medicare
Part B premiums) paid to or on behalf of
applicant. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Pension and Retirement Benefits (including
IRA and annuity income) See instructions for
calculating amount. . . . . . . . . . . . . . . . . . . . .
c. Salaries, Wages, Bonuses, Commissions, and
Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. Unemployment Benefits . . . . . . . . . . . . . . . . .
e. Disability Benefits, whether public or private
(including veterans’ and black lung benefits). .
f. Interest (taxable and exempt). . . . . . . . . . . . .
g. Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . .
h. Capital Gains . . . . . . . . . . . . . . . . . . . . . . . .
i. Net Rental Income . . . . . . . . . . . . . . . . . . . .
j. Net Profits From Business . . . . . . . . . . . . . . .
k. Net Distributive Share of Partnership Income .
l. Net Pro Rata Share of S Corporation Income .
m. Support Payments . . . . . . . . . . . . . . . . . . . . .
n. Inheritances, Bequests, and Death Benefits . .
o. Royalties . . . . . . . . . . . . . . . . . . . . . . . . . . . .
p. Gambling and Lottery Winnings
(including New Jersey Lottery) . . . . . . . . . . . .
q. All Other Income . . . . . . . . . . . . . . . . . . . . . .
,
.
,
.
Add lines a-q in each column. Enter total
2013 income on Line 7 and total 2014
7. TOTAL 2013 INCOME
8. TOTAL 2014 INCOME
income on Line 8.
Was your total 2013 income on
Was your total 2014 income on
Total annual income cannot à
Line 7 $84,289* or less?
Line 8 $85,553* or less?
exceed amounts shown.
Yes. See 2014 income eligibility.
Yes. Go to page 3.
No. STOP. You are not eligible
No. STOP. You are not eligible
for the reimbursement and you
for the reimbursement and you
should not file this application.
should not file this application.
*Subject to change by State Budget.
*Subject to change by State Budget.
CONTINUE TO PAGE 3 à
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Parent category: Business