Form Ptr-1 - Property Tax Reimbursement Application - 2004
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2STATE OF NEW JERSEY
PTR-1
2004 PROPERTY TAX REIMBURSEMENT APPLICATION
You must enter your social security number below
Your Social Security Number
Last Name, First Name and Initial
(Joint applicants enter first name and initial of each - Enter spouse last name ONLY if different)
Spouse’s Social Security Number
Home Address (Number and Street, including apartment number or rural route)
City, Town, Post Office
State
Zip Code
County/Municipality Code (See Table page 11)
1. Residency Status:
Homeowner
Mobile Home Owner
2. Your 2003 Marital Status:
Single
Married
3. Your 2004 Marital Status:
Single
Married
4a. On December 31, 2003, I (or my spouse) was
Age 65 or older
Receiving Federal Social Security Disability Benefits.
Fill in only one oval. If you (or your spouse) were 65 or older and also receiving disability benefits, fill in the oval to the left of “Age 65
or older.” Documentation of age or disability is required. See reverse for acceptable forms of proof. If you (and your spouse)
do not meet the age or disability requirement, you are not eligible for the reimbursement and you should not file this application.
4b. If you (or your spouse) were receiving Federal Social Security Disability Benefits on December 31, 2003, was that same person still
receiving benefits on December 31, 2004?
Yes
No. If “No,” STOP. You are not eligible for the reimbursement and you should
not file this application.
5. Did you live in New Jersey continuously since before January 1, 1994, as either a homeowner or a renter?
Yes
No. If “No,”
STOP. You are not eligible for the reimbursement and you should not file this application.
6. Did you own and live in your New Jersey home (or lease a site in a mobile home park in New Jersey on which you placed a
manufactured or mobile home that you own) since before January 1, 2001?
Yes
No. If “No” STOP. You are not eligible for the
reimbursement and you should not file this application.
7. Complete Income Worksheet A (on reverse) and enter the amount of 2003 Total Income
7.
,
.
from Line p. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8. Complete Income Worksheet B (on reverse) and enter the amount of 2004 Total Income
8.
,
.
from Line p. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Enter the address for which you are claiming the reimbursement if different from above.
Street address ____________________________________________________ Municipality ______________________________
10. Homeowners: Enter the block and lot number of the residence for which the property tax reimbursement is being claimed.
Block
Lot
Qualifier
2003
2004
11a. Did you share ownership of your principal residence with anyone
other than your spouse? (Mobile Home Owners see instructions.) . . . . . . . . . . . . . . .
Yes
No
Yes
No
11b. If you answered “Yes,” indicate the share (percentage) of the property
%
%
owned by you (and your spouse) (Mobile Home Owners see instructions.) . . . . . . . . .
12a. Does your principal residence consist of more than one unit? . . . . . . . . . . . . . . . . . . .
Yes
No
Yes
No
12b. If you answered “Yes,” indicate the share (percentage) of the property
%
%
that you (and your spouse) occupy as your principal residence. . . . . . . . . . . . . . . . . .
If you answered “Yes” at Line 11a or Line 12a, the amount of property taxes you report on Lines 13 and 14 must be apportioned. See
instructions. If enclosed, use the amounts of property taxes (or site fees) from Form PTR-1A (or PTR-1B) to complete Lines 13 and 14.
13.
Enter your total 2004 property taxes due and paid on your principal residence. (Mobile
13.
Home Owners enter 18% of total 2004 site fees due and paid $________________ x .18)
,
.
14.
Enter your total 2003 property taxes due and paid on your principal residence. (Mobile
14.
.
Home Owners enter 18% of total 2003 site fees due and paid $________________ x .18)
,
REIMBURSEMENT AMOUNT
15.
,
15. Subtract Line 14 from Line 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
If Line 15 is zero or less, you are not eligible for a property tax reimbursement and you should not file this application.
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Division Use
Under the penalties of perjury, I declare that I have examined this Property Tax Reimbursement Application, including accompanying schedules
Due Date: June 1, 2005
and statements, and to the best of my knowledge and belief, it is true, correct, and complete. If prepared by a person other than applicant,
this declaration is based on all information of which the preparer has any knowledge.
Mail your completed application to:
________________________________________________________ ______________________________________________________
NJ Division of Taxation
Revenue Processing Center
Your Signature
Date
Spouse’s Signature (if applying jointly, BOTH must sign)
Property Tax Reimbursement
Paid Preparer’s Signature
Federal Identification Number
PO Box 635
Trenton, NJ 08646-0635
Firm’s Name
Federal Employer Identification Number
Property Tax Reimbursement
Hotline: 1-800-882-6597
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