New Jersey
                                                                                                                                 2019 Senior Freeze
                                                PTR-1
                                                                                                               (Property Tax Reimbursement) Application
                                                                                                               Place preprinted label below ONLY if the information is correct.
                                                 You must enter your Social Security number below                     Otherwise print or type your name and address.
                                                Your Social Security Number                        Last Name, First Name, Initial (Joint Filers enter first name and middle initial of each. Enter  
                                                                                                                                 spouse’s/CU partner’s last name ONLY if different.)
                                                         -  -

                                                Spouse’s/CU Partner’s SSN                          Home Address (Number and Street, including apartment number)
                                                         -  -
         
         County/MunicipalityCode                            (See instructions)                     City, Town, Post Office                 State                               ZIP Code

 For Privacy Act Notification, See Instructions               

                                                 This is a four-page application. You must complete all four pages. Fill in ovals completely. 

                                                 PROOF OF AGE OR DISABILITY FOR 2018 AND 2019 MUST BE SUBMITTED WITH APPLICATION
                                                 Age 65 or Older: Copy of one – Birth Certificate, Driver’s License, Church Records
                                                 Receiving Federal Social Security Disability Benefits: Copy of Social Security Award Letter
                                                                                                   See instructions for more information.

Marital/Civil Union Status 

1.  Your Marital/Civil Union Status on December 31, 2018:                                                                          Single    Married/CU Couple

2.   Your Marital/Civil Union Status on December 31, 2019:                                                                         Single    Married/CU Couple

Age/Disability Status
3a.  On December 31, 2018, were you age 65 or older?                                                           Yourself                      Yes                                No
                                                                                                               Spouse/CU Partner             Yes                                No

3b.  On or before December 31, 2018, were you actually  Yourself                                                                             Yes                                No
                                                receiving federal Social Security disability benefit           Spouse/CU Partner             Yes                                No
                                                payments?

4a.  On December 31, 2019, were you age 65 or older?                                                           Yourself                      Yes                                No
                                                                                                               Spouse/CU Partner             Yes                                No

4b.  On or before December 31, 2019, were you actually  Yourself                                                                             Yes                                No
                                                receiving federal Social Security disability benefit           Spouse/CU Partner             Yes                                No
                                                payments?
Applicant(s) must meet the age or disability requirements for both 2018 and 2019. If neither you nor your spouse/CU 
partner met the requirements, you are not eligible for the reimbursement, and you should not file this application. See 
“Eligibility Requirements” on page 1 of instructions.

Residency Requirements
5.   Have you lived in New Jersey continuously since December 31, 2008,
                                                or earlier 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.   Have you owned and lived in the same New Jersey home since
                                                December 31, 2015, or earlier? (Mobile Home Owners, see instructions)                        Yes                                No
                                                If “No,” STOP. You are not eligible for the reimbursement, and you should not file this application. 

                                                             Name(s) as shown on Form PTR-1                Your Social Security Number
PTR-1 (2019) Page 2

Determining Total Income (Line 7): Enter your annual income for 2018. See “Income Standards” and “Determining Total Income” in 
the instructions for information on sources of income and how to determine the amount to report. If you had no income in a 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 2018 and living in the same home, 
combine your incomes for that year. If you lived in separate homes, file as “Single.”

                                     2018 Income

a. Social Security Benefits (including Medicare Part B   
 premiums) paid to or on behalf of applicant. Enter total  
 amount from Box 5 of Form SSA-1099 or Form RRB-1099 .......a.                                          , .
b. Pension and Retirement Benefits (including IRA and   
 annuity income) See instructions for calculating amount  ..........b.                                  , .

c. Salaries, Wages, Bonuses, Commissions, and Fees  ................c.                                  , .

d. Unemployment Benefits .............................................................d.                , .
e. Disability Benefits, whether public or private (including  
 veterans’ and black lung benefits) ..............................................e.                    , .

f.  Interest (taxable and exempt) ......................................................f.              , .

g. Dividends ....................................................................................g.     , .

h. Capital Gains ..............................................................................h.       , .

i.  Net Rental Income .......................................................................i.         , .

j.  Net Profits From Business ...........................................................j.             , .

k. Net Distributive Share of Partnership Income ............................k.                          , .

l.  Net Pro Rata Share of S Corporation Income .............................l.                          , .

m. Support Payments .....................................................................m.             , .

n. Inheritances, Bequests, and Death Benefits ..............................n.                          , .

o. Royalties .....................................................................................o.    , .
p. Gambling and Lottery Winnings (including New  
 Jersey Lottery) ............................................................................p.         , .

q. All Other Income .........................................................................q.         , .
7.  Enter total 2018 income on line 7. (Add lines a-q) ..................                             7.
                                                                                                        , .

 Was your total 2018 income on line 7 $89,013 or less?
    Yes. See 2019 income eligibility.
    No. STOP. You are not eligible for the reimbursement, and you should not file this application.

                                                             Name(s) as shown on Form PTR-1             Your Social Security Number
PTR-1 (2019) Page 3

Determining Total Income (Line 8): Enter your annual income for 2019. See “Income Standards” and “Determining Total Income” in 
the instructions for information on sources of income and how to determine the amount to report. If you had no income in a 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 2019 and living in the same home, com-
bine your incomes for that year. If you lived in separate homes, file as “Single.”

                                   2019 Income

a. Social Security Benefits (including Medicare Part B   
 premiums) paid to or on behalf of applicant. Enter total  
 amount from Box 5 of Form SSA-1099 or Form RRB-1099 .......a.                                       , .
b. Pension and Retirement Benefits (including IRA and   
 annuity income) See instructions for calculating amount  ..........b.                               , .

c. Salaries, Wages, Bonuses, Commissions, and Fees  ................c.                               , .

d. Unemployment Benefits .............................................................d.             , .
e. Disability Benefits, whether public or private (including  
 veterans’ and black lung benefits) ..............................................e.                 , .

f.  Interest (taxable and exempt) ......................................................f.           , .

g. Dividends ....................................................................................g.  , .

h. Capital Gains ..............................................................................h.    , .

i.  Net Rental Income .......................................................................i.      , .

j.  Net Profits From Business ...........................................................j.          , .

k. Net Distributive Share of Partnership Income ............................k.                       , .

l.  Net Pro Rata Share of S Corporation Income .............................l.                       , .

m. Support Payments .....................................................................m.          , .

n. Inheritances, Bequests, and Death Benefits ..............................n.                       , .

o. Royalties .....................................................................................o. , .
p. Gambling and Lottery Winnings (including New  
 Jersey Lottery) ............................................................................p.      , .

q. All Other Income .........................................................................q.      , .
8.  Enter total 2019 income on line 8. (Add lines a-q) ..................  8.
                                                                                                     , .

 Was your total 2019 income on line 8 $91,505 or less?
 (See “Impact of State Budget” on page 1 of instructions, which explains how the state budget may reduce the income limit.)

    Yes. Go to page 4. 
    No. STOP. You are not eligible for the reimbursement, and you should not file this application.

                                                                           Name(s) as shown on Form PTR-1                                    Your Social Security Number
PTR-1 (2019) Page 4

Principal Residence
  9.           Status (fill in appropriate oval):                          Homeowner                                                Mobile Home Owner
  10.          Homeowners: Enter the block and lot numbers of your 2019 principal residence.
               Block                                 Lot                                                                            Qualifier
                                         .                                    .                                                   

                                                                                                                                    2018                 2019
 11a.          Did you share ownership of this property with anyone other 
               than your spouse/CU Partner? (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/CU partner) (Mobile Home Owners,                                                              %                         %
                                                                                                                                            
               see instructions)  ..........................................................................................

 12a.          Did this property consist of multiple units? ...................................................                    Yes       No         Yes           No
 12b.          If you answered “Yes,” indicate the share (percentage) of the property 
               that you (and your spouse/CU partner) used as your principal residence.  ..                                                  %                        %

If you answered “Yes” at line 11a or 12a, see instructions before completing lines 13 and 14.

Property Taxes
Proof of Property Taxes Due and Paid for 2018 and 2019 Must be Submitted With Application. See Instructions.
  If you are claiming property taxes for additional lots, check box. (See instructions) 
  13.          Enter your total 2019 property taxes due and paid (including any 
               credits/deductions) on your principal residence. See instructions.
               (Mobile Home Owners: Property taxes = total site fees paid X 0.18) .........                                   13.
                                                                                                                                           ,             .
  14.          Enter your total 2018 property taxes due and paid (including any 
               credits/deductions) on your principal residence. See instructions.
               (Mobile Home Owners: Property taxes = total site fees paid X 0.18) .........                                   14.
                                                                                                                                           ,             .

Reimbursement Amount                       (See “Impact of State Budget” on page 1 of instructions.)
  15.          Reimbursement. (Amount to be sent to you. Subtract line 14 
               from line 13) ................................................................................................ 15.
                                                                                                                                           ,             .
If line 15 is zero or less, you are not eligible for a reimbursement, and you should not file this application.
            If enclosing copy of death certificate for deceased applicant, check box. (See instructions) 
            Under penalties of perjury, I declare that I have examined this Senior Freeze (Property Tax Reimbursement) Application, 
            including accompanying schedules 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 Due Date: November 2, 2020
            any knowledge.                                                                                                                 Mail your completed application 
                                                                                                                                           to :
                                                                                                                                             NJ Division of Taxation
            Your Signature                   Date   Spouse’s/CU Partner’s Signature (if filing jointly, BOTH must sign)                      Revenue Processing Center
                                                                                                                                             Senior Freeze (PTR)
            Your daytime telephone number and/or email address (optional)                                                                    PO Box 635
                                                                                                                                             Trenton, NJ, 08646-0635
  SIGN HERE    Paid Preparer’s Signature             Federal Identification Number
                                                                                                                                           Senior Freeze (PTR) Hotline: 
                                                                                                                                           1-800-882-6597
               Firm’s name                           Federal Employer Identification Number

 Division Use                1             2         3                     4         5                                              6                    7. .