STATE OF NEW JERSEY                               PTR 
                        2019 SENIOR FREEZE (PROPERTY TAX REIMBURSEMENT)                                      INCOME REPORT

Social Security Number: ________________________-          -                   Spouse’s/CU Partner’s Social Security Number:                    -         -               _______________________
Name: ___________________________________________________________________________________________
DETERMINING INCOME
See the instructions for information on possible sources of income and how to determine the amount to be reported in each category. If you
had no income in a particular 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 
and living in the same household, combine your incomes for that year. If you lived in separate households, file as “single.” 
 INCOME CATEGORIES                                                         2018                              2019
  a. Social Security Benefits (including Medicare
 Part B premiums) paid to or on behalf of appli-
 cant. Enter total amount from Box 5 of Form
 SSA-1099 or Form RRB-1099 . . . . . . . . . . . . .
  b. Pension and Retirement Benefits (including
 IRA and annuity income) See instructions for
 calculating amount. . . . . . . . . . . . . . . . . . . . . 
  c. Salaries, Wages, Bonuses, Commissions, and
 Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
  d. Unemployment Benefits . . . . . . . . . . . . . . . . .
  e. Disability Benefits, whether public or private
 (including veterans’ and black lung benefits). . 
   f. Interest (taxable and exempt). . . . . . . . . . . . . 

  g. Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . 

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

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

   j. Net Profits From Business . . . . . . . . . . . . . . . 
  k. Net Distributive Share of Partnership Income . 

   l. Net Pro Rata Share of S Corporation Income . 

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

  n. Inheritances, Bequests, and Death Benefits . . 
  o. Royalties . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  p. Gambling and Lottery Winnings
 (including New Jersey Lottery) . . . . . . . . . . . .
  q. All Other Income . . . . . . . . . . . . . . . . . . . . . . 

                                                                           ,                                 ,
 Add lines a-q in each column.                                                         .                                     .
                                                                           TOTAL 2018 INCOME                 TOTAL 2019 INCOME

   Total annual income cannot à                                       Was your total 2018 income        Was your total 2019 income 
 exceed amounts shown.                                                $89,013 or less?                  $91,505 or less?
                                                                                                        (See “Impact of State Budget” on page 1 of
                                                                                                        the instructions which explains how the State
                                                                                                        Budget may reduce the income limit.)
                                                                      Yes. See 2019 income eligibility. Yes. You met 2019 income limit.

                                                                      No.STOP. You are not eligible     No.  STOP. You are not eligible 
                                                                      for the reimbursement, and you           for the reimbursement, and you 
                                                                      should not file this application.        should not file this application.