Application for Tax Clearance 

                                             Business Assistance and Incentives 
   (3/23) 

This form is not for business dissolutions. 
Use this form if you need a tax clearance certificate for a grant, loan, loan guarantee, rebate, tax credit, or other monetary incentive issued by a New Jersey 
agency or authority. If the applicant has not filed or paid all required tax obligations, the Division of Taxation will not issue a tax clearance certificate. However, the 
Division will notify the applicant of what needs to be resolved in order to have a tax clearance certificate issued. 

Applicant Information 

Legal Name of Applicant: 

Trade Name of Applicant: 

Business Location or Home Address: 

Mailing Address for Clearance Certificate: (If different from Business Location or Home Address) 

NJ Tax Registration #:                                                                                               EIN/SSN :

Agency Issuing Assistance/Incentive: 
(This information is required to process this application.) 
Name of Agency: 

Name of Assistance/Incentive Program: 

Agency Contact Person: 

Agency Contact Phone #: 

Agency Contact Email: 

I certify that I am authorized to complete this tax clearance application. I affirm that the information provided herein is true and complete, and that I will be held 
personally liable under penalties of perjury for making any false statements. (N.J.S.A. 2C:28-1) 

I understand that the Division of Taxation may communicate to the issuer State agency, the status of the tax compliance of the applicant. By signing this tax 
clearance application, I consent to the release of such general status information by the Division of Taxation. 

Signature of Authorized Representative 

Print Name:                                                                                                          Title: 

Contact Phone #:                                                                                                     Date: 

Email Address: 

                          We will not process this application if you do not provide a contact phone number and/or email. 

List of Officers, Partners or Members: 
(Attach additional sheets if necessary) 
Name:                                                                                    SSN: 

Address: 

Name:                                                                                    SSN: 

Address: 

Name:                                                                                    SSN: 

Address: 

Parent Company, Subsidiary, or other Related Entity That Will Directly Benefit From This Assistance: 
(Attach additional sheets if necessary) 
Name:                                                                                    Taxpayer ID #: 

Address: 

Relationship:                                                                            Type of Business: 

Name:                                                                                    Taxpayer ID #: 

Address: 

Relationship:                                                                            Type of Business: 

P.L. 2007,c.101  established  a tax clearance  program  for awards  of certain  business assistance and incentive programs, including but not limited to a grant, 
loan, loan guarantee, or other monetary or financial benefit issued by New Jersey and its independent agencies and authorities to  assist in the conduct or 
operation of a business, occupation, trade, or profession in New Jersey. As a precondition to,  or  as  a  component  of, the  application  process, the  applicant 
must  provide  to the State agency a current tax clearance certificate issued by the Director of the Division of Taxation. 

Mandatory Application Fees: 
Standard Processing - $75.00 
Expedited Processing (response within three (3) business days) - $200.00.  
Payment must be made by check or money order payable to the “New Jersey Division of Taxation”. 
The fee is non-refundable and entitles the applicant to updated tax clearance certificates for up to one year from the date of application.. 

Mail this application and fee to:  
State of New Jersey 
Division of Taxation 
Business Assistance Tax Clearance Unit 
3 John Fitch Way – 4th Floor 
P.O. Box 272 
Trenton, NJ 08695-0272 
For questions about the tax clearance process call  (609) 322-6835 or email BusinessAssistanceTC.Taxation@treas.nj.gov  
All other questions should be directed to the agency providing the assistance/incentive.