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            Application for Tax Clearance – Business Assistance and Incentives 

                                   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 Tax 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.                                               



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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 8 thFloor 
P.O. Box 272 
Trenton, NJ 08695-0272 
Questions about the tax clearance process may be directed to:  (609) 322-6835 or email 
BusinessAssistanceTC.Taxation@treas.nj.gov . 
All other questions should be directed to the agency providing the assistance/incentive. 






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