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Lebanon (City)Green Risk

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Supplemental Income Form Must be Included with Senior Citizen & Disabled Person Application

BID #: PTD-SI

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VALUE: TBD

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Executive Summary

This document is a Supplemental Income Form (PTD-SI) required to be included with a Senior Citizen & Disabled Person Application for a $250 Real Property Tax Deduction. The form collects detailed income information from the applicant (and spouse, if applicable) to determine eligibility for the deduction based on income requirements. The assessor or collector may request federal income tax records to substantiate the provided income statement.

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--- Document: Supplemental Income Form Must be Included with Senior Citizen & Disabled Person Application Document ---
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)