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                           State of New Jersey 
                           Division of Taxation 

                           Form 906  
                             
     CLOSING AGREEMENT REQUEST  
                                                                                      
Enclosed packet includes:  
  
  1. A copy of the Closing Agreement statute.  
    
  2. A Closing Agreement Form 906 to complete.  
  
  3. Appointment of Taxpayer Representative, if applicable.  
  
  4. A Financial Statement of Debtor – Section I through Section V to be completed.  
  
  5. National Standard Expenses information to be used in the completion of  Section 
     II of Financial Statement of Debtor.  
  
NOTE:  Copies of the Taxpayer’s last two years Individual IRS returns, and 
Corporate returns, if applicable, are required to be submitted with Form 906.  
  
                          Send completed required information to:  
                             
                           New Jersey Division of Taxation  
                            Closing Agreements 
                           PO Box 245 
                           Trenton, NJ 08695-0245

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                                        Closing Agreements  
                                                       
                                                     Authority  
   
 Unless otherwise expressly noted, all provisions of this chapter were adopted pursuant to authority of 
 N.J.S.A. 54:50-1 et seq. and were filed and became effective on January 27, 1978, as R. 1978 d. 29 Sec: 
 10 N.J.R. 41(a), N.J.R. 127(d).  
   
                                        Chapter Table of Contents  
                          
 SUBCHAPTER 1            Closing Agreements  
   
         18:33-1.1       General provisions  
         18:33-1.2       Taxable periods  
         18:33-1.3       Finality; determination of fraud  
         18:33-1.4       Procedure with respect to closing agreements  
         18:33-1.5       Applicability and coverage; policy  
         18:33-1.6       Procedures  
   
 18:33-1.1     General provisions  
   
 (a) The Director of the Division of Taxation or any of his delegated representatives may enter into a 
 written agreement with any person relating to the liability of such person (or of the person or estate for 
 whom he acts) in respect to any State tax administered by the Director of the Division of Taxation for any 
 taxable period ending prior or subsequent to the date of such agreement. A closing agreement may be 
 entered into in any case in which there appears to be an advantage in having the case permanently and 
 conclusively closed, or if good and sufficient reasons are shown by the taxpayer for desiring a closing 
 agreement and it is determined by the director that the State of New Jersey will sustain no disadvantage 
 through consummation of such an agreement.  
 (b) A closing agreement may be executed even though under the agreement the taxpayer is not liable for 
 any tax for the period to which the agreement relates. There may be a series of closing agreements 
 relating to the tax liability for a single period.  
   
 18:33-1.2     Taxable periods  
   
 (a) Closing agreements with respect to taxable periods ended prior to the date of the agreement may relate 
 to the total tax liability of the taxpayer or to any or more separate items affecting the tax liability of the 
 taxpayer, as, for example, the amount of gross receipt, deduction items, other income items, statutory 
 deductions or exclusions, statutory additions to income, the year in which an item of income is to be 
 included in gross receipts or income, the year in which an item is to be deducted, or the value of property 
 on a specific date.  
 (b) Closing agreements with respect to taxable periods ending subsequent to the date of the agreement 
 may relate to one or more separate items affecting the tax liability of the taxpayer.  
   
 18:33-1.3     Finality; determination of fraud  
   
         (a) A closing agreement which is approved within such time as may be stated in such agreement, 
 or later agreed to, shall be final an conclusive, and, expect upon a showing of fraud or malfeasance, or 
 misrepresentation of a material fact.

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                 1. The case shall not be reopened as to the matters agreed upon or the agreement 
                     modified by an officer, employee, or agent of the State of New Jersey; and  
                 2. In any suit, action, or  proceeding, such  agreement, or  any determination, 
                     assessment, collection, payment, abatement, refund, or credit made in accordance 
                     therewith, shall  
                     not be annulled, modified, set aside, or disregarded. However, a closing agreement 
                     with respect to a taxable period ending subsequent to the date of the agreement is 
                     subject to any change in, or modification of, the law enacted subsequent to the date 
                     of the agreement and made applicable to such taxable period, and each closing 
                     agreement so recited.  
         (b) Execution and approval of closing agreement does not preclude an additional inspection of the 
 taxpayer’s records to determine whether fraud, malfeasance, or misrepresentation of material fact exists as 
 to execution of agreement.  
   
 18:33-1.4       Procedure with respect to closing agreements  
           
         (a) A request for a closing agreement which relates to a prior taxable period may be submitted at 
 any time before a case with respect to the tax liability involved is filed in the Division of Tax Appeals. All 
 closing agreements shall be executed on forms prescribed by the Director of the Division of Taxation.  
         (b) Any tax or deficiency in tax determined pursuant to a closing agreement shall be assessed and 
 collected, and any overpayment determined pursuant thereto shall be credited or refunded, in accordance 
 with the applicable provisions of law.  
   
 18:33-1.5       Applicability and coverage; policy  
   
 (a) The Director of the Division of Taxation or any Division of Taxation officer or employee authorized in 
 writing by the Director,  can enter  and  approve written closing agreements  with  any person.  Such 
 agreement can relate to the liability of such person (or the taxpayer represented by him), for any State tax 
 administered by the Division of Taxation for any taxable period. The agreement can cover either the total 
 liability of taxpayer or one or more of separate items affecting the liability, if it embraces a tax period 
 ending before the date of the agreement; or one or more separate items affecting tax liability.   
 There can be a series of agreements covering a single tax period.  
 (b) A closing agreement may be entered into when it appears advantageous to have the case permanently 
 closed; or where the taxpayer shows sufficient reason for desiring a closing agreement, and there would 
 be no disadvantage to the State of New Jersey in entering into it. Closing agreements can be entered into, 
 although under the agreement taxpayer is not liable for tax for the period covered.  
   
 18:33-1.6       Procedures  
   
         (a) A request to enter into a closing agreement is executed on prescribed forms and submitted, 
 processed and approved under prescribed procedure. If the proposed agreement relates to a prior taxable 
 period, it must be submitted before a case with respect to the tax liability is filed in the Division of Tax 
 Appeals or in any Division of the Superior Court of New Jersey or in any Federal Court.  
         (b) Where parties entered into a stipulation, on trial, or any matter regarding taxpayer’s liability, 
 and the action is dismissed with prejudice, taxpayer shall not be permitted to repudiate the agreement 
 because a closing agreement was not executed by the Director of the Division of Taxation.  
         (c) Taxpayer’s acceptance of  a determination of  additional  tax under which an assessment  of 
 additional tax was made and paid,  does not preclude the Director from determining an additional 
 deficiency for the year.  
         (d) The Director of the Division of Taxation is not estopped from issuing a deficiency assessment.  
 Acceptance  of  a  sum  submitted  with  an  amended  return  does  not  discharge  a  taxpayer  from  further 
 liability; a deficiency assessment is not a closing agreement.

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                  Appointment of Taxpayer Representative (Form M-5008-R) 

1.   Taxpayer Information
Use this form to designate a representative(s) and grant the representative(s) the authority to obligate, bind, and/or appear on 
your behalf before the New  Jersey Division of Taxation. Section 3 of the  form allows  you to list  which tax  matters  your 
representative is authorized to handle on your behalf.  
Taxpayer Is: 

☐ Individual    ☐ Corporation      Sole☐ Proprietorship      Partnership      ☐ Estate           ☐ Limited☐Liability Company
☐Trust(other than a business trust)          Other Specify__________________________________________________________ 
Taxpayer’s Name                                                                 Social Security Number 

Spouse’s/CU Partner’s Name                                                      Social Security Number 

Mailing Address                                                                                            Country 
                                                                                                           (If not US) 
City                                                            State                                      Zip 

NJ Taxpayer ID Number (if other than SS#) 

Name of Trustee or Executor 

Address of Trustee or Executor                                                                             Country 
                                                                                                           (If not US) 
City                                                                            State                      Zip 

2.   Representative Information
The named representative(s) must sign and date where indicated in Section 8 on page 2 or this appointment will be rejected. If 
the representative is a tax practitioner, the representative must enter his/her Preparer Tax Identification Number (PTIN) as the 
Representative ID. Representatives who do not have a PTIN must enter their Social Security number. The taxpayer(s) named in 
Section 1 above appoints the person(s) named below as his/her/their taxpayer representative to represent them in connection 
with the tax matter(s) listed in Section 3.  
Name                                                                            Representative ID 

Address 

Telephone Number                                                                Fax Number 

Name                                                                            Representative ID 

Address 

Telephone Number                                                                Fax Number 

3.   Tax Matters
I/We appoint the representative(s) named in Section 2 above to represent me/us for:
☐All tax matters  ☐Specific tax matters listed below
Type of Tax (New Jersey Gross Income, Sales and Use, Corporation,  Years(s) & Period(s) 
Partnership, Employment, Inheritance, etc.)

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4. Acts Authorized
The representative(s) is/are authorized to receive and inspect confidential tax records and is/are granted full power to act with
respect to the tax matters described in Section 3 above, and to do and perform all such acts as I/we could do or perform. The
authority granted by this appointment does not include the power to endorse a refund check.

☐If you want the representative(s) to have limited power, provide an explanation on the lines below and check this box. You may
attach additional information as well.

5. Notices and Communications (audit correspondence only)
We will send original notices and other written communications to you and a copy (other than automated computer notices) to the
first representative listed in Section 2 unless you check one or more of the boxes below.

☐I/We do not want the Division to send any notices or communications to my representative(s).

☐I/We want the Division to send a copy of notices and/or communications (other than automated computer notices) to both
representatives listed in Section 2.

6. Retention/Revocation of Prior Appointment(s) or Power(s)
The filing of this form automatically revokes all earlier Appointment(s) of Taxpayer Representative and/or Power(s) of Attorney
on file with the Division of Taxation for the tax matters and years or periods listed in Section 3 unless you check the box below.

☐I/We do not want to revoke any prior Appointment(s) of Taxpayer Representative and/or Power(s) of Attorney. If you check
this box, you must attach copies of the previous Appointment(s) and/or Power(s) that you do not want to revoke.

7. Signature of Taxpayer(s)
If the tax matters covered by this appointment concern a joint Gross Income Tax return and the representative(s) is/are being
appointed to represent both spouses/CU partners, both must sign below.
If a corporate officer, partner, guardian, tax matter partner, executor, administrator, or trustee signs the appointment on behalf
of the taxpayer, the signature below certifies that they have the authority to execute this form on behalf of the taxpayer(s).
This Appointment of Taxpayer Representative Is Void if not Signed and Dated
Taxpayer Signature Date

Print Name Title (if applicable)

Taxpayer Signature Date

Print Name Title (if applicable)

8. Acceptance of Representation and Signature
I/ We accept the appointment as representative(s) for the taxpayer(s) who has/have executed this Appointment of Taxpayer
Representative.
Representative Signature Date

Print Name Title (if applicable)

Representative Signature Date

Print Name Title (if applicable)

Instructions for Form M-5008-R
Use this form to designate a representative(s) and grant the representative(s) the authority to obligate, bind, and/or appear on your
behalf before the New Jersey Division of Taxation. Section 3 of the form allows you to list which tax matters your representative
is authorized to handle on your behalf.

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You  may authorize the representative(s) to receive your confidential tax information. Unless otherwise indicated, the 
representative(s) may also perform any and all acts that you can perform regarding your taxes. This includes consenting to extend 
the time to assess tax or agreeing to a tax adjustment. Representatives may not sign returns or delegate authority unless specifically 
authorized to do so on this form.  
Form M-5008-R Is not Required:  
• When an individual appears with you or with a representative who is authorized to act on your behalf. For example, this 
form is not required if a representative appears on behalf of a corporate taxpayer with an authorized corporate officer;  
• If a trustee, receiver, or attorney has been appointed by a court that has jurisdiction over a debtor;  
• If an individual merely furnishes tax information or prepares a report or return for you;  
• When a fiduciary  stands in the position of, and acts as, the taxpayer. However, if a fiduciary  wishes to authorize an 
individual to represent or act on behalf of the taxpayer, the fiduciary must sign and file Form M-5008-R.  
Limitations  
Appointing a representative does not relieve you of tax responsibilities or obligations. This form allows another person to represent 
you in most matters concerning tax administration, tax investigations, examinations/audits, and other meetings with the Division. 
Because you remain responsible for your tax obligations,  a representative’s authority does not extend to some aspects of the 
collection process. Examples of the collection process are: judgments, levies, liens, and seizures. In  these instances,  we  may 
require telephone communication, direct contact, and/or interaction with the taxpayer.   
Who Can Execute the Appointment of Taxpayer Representative?  
• An individual, if the request pertains to a personal Income or individual Use Tax return filed by that individual (or by an 
individual and his or her spouse/CU partner if the request pertains to a joint Income Tax return and joint representation is 
requested). If joint representation is not requested, each taxpayer must file his or her own form.  
• If the taxpayer is a limited liability company (LLC), a manager of the LLC. If there is no manager, a member of the LLC 
authorized to act on tax matters on behalf of the entity.  
• A sole proprietor.  
• A general partner of a partnership or limited partnership.  
• The administrator or executor of an estate.  
• The trustee of a trust.  
• If the taxpayer is a corporation, a principal officer or corporate officer who is authorized to act on tax matters and has 
legal authority to reach agreements on behalf of the corporation; any person who is designated by the board of directors or 
other governing body of the corporation; any officer or employee of the corporation upon written request signed by a principal 
officer of the corporation and attested by the secretary or other officer of the corporation; or any other person who is 
authorized to receive or inspect the corporation’s return or return information under I.R.C. §6103(e)(1)(D).  
Tax Matters  
You may enter more than one tax type and indicate the tax year(s) and/or tax period(s) applicable in Section 3. If you designate a 
specific tax but no tax year or period, the M-5008-R will apply to all tax years and periods. If you designate a specific tax year or 
period but not a specific tax type, this form will apply to all tax types for the designated tax year or period. If you do not designate 
either a tax type or a tax period, this form will apply to all taxes and all periods.  
Retention/Revocation of Prior Powers of Attorney and/or Appointments of Taxpayer Representative  
By executing and filing the M-5008-R with the Division of Taxation, you are revoking all M-5008-R previously executed and filed 
with this Division for the same tax matter(s), year(s), and period(s) covered by this form.  
You may not partially revoke a previously filed Form M-5008-R. If a previously filed Form M-5008-R or Power of Attorney has 
more than one representative and you do not want to retain all the representatives on the previously filed form, you must execute a 
new form indicating the representative(s) retained.  
Signature of Taxpayer(s)  
You, or an individual  you authorize to execute the Form  M-5008-R on  your behalf,  must sign and date the  form. You or the 
representative(s) may be required to provide identification and evidence of authority to sign this document.  
Individuals. If the matter for which the appointment is prepared involves a joint Income Tax return and the same individual(s) will 
represent both spouses/CU partners, both  must sign Form M-5008-R,  unless one  spouse/CU partner authorizes the other, in 
writing, to sign for both. In that case, you must attach a copy of the authorization to the appointment. If the matter for which the

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appointment is prepared involves a joint return and different individuals will represent the spouses/CU partners, each must execute
his or her own Appointment of Taxpayer Representative.
Corporations. The president, vice-president, treasurer, assistant treasurer, or any other officer of the corporation having authority
to bind the corporation must sign Form M-5008-R.
Partnerships. All partners must sign Form M-5008-R, or if the form is executed on behalf of the partnership only, a partner duly
authorized to act for the partnership must sign it. A partner is authorized to act for the partnership if, under state law, the partner
has authority to bind the partnership.
Limited Liability Companies (LLC). A member or manager must sign Form M-5008-R, or, if the form is executed on behalf of
the LLC only, a member or manager duly authorized to act for the LLC must sign it, and the signor must certify that he/she has
such authority.
Fiduciaries. In matters involving fiduciaries under agreements, declarations, or appointments, Form M-5008-R must be signed by
all of the fiduciaries, unless proof is furnished that fewer than all fiduciaries have the authority to act in the matter under
consideration. Evidence of the authority of the fiduciaries to act must be included when filing Form M-5008-R.
Estates. The administrator or executor of an estate may execute Form M-5008-R.
Trusts. The trustee of a trust may execute Form M-5008-R.
Others. Form M-5008-R must be signed by the taxpayer or by an individual having the authority to act on behalf of the taxpayer.
Instructions for Submission
Completion and submission of this form is only required when you are communicating – either in person or in writing – with the
Division on behalf of another person.
In Person
If you are planning to visit a Regional Information Center on behalf of another individual, you must bring:
• The completed form, signed by both the representative and the taxpayer; and
• One form of government-issued photo identification (such as a driver’s license) ortwo forms of non-picture government-
issued identification (such as a birth certificate).
In Writing
If you are responding to a notice sent by the Division, submit your documentation to the PO Box on the notice.
You must include with your correspondence:
• The completed form, signed by both the representative and the taxpayer;
• A copy of the notice; and
• Any corresponding documentation.

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                  New Jersey Treasury Department – Division of Taxation  
                                                                  
                  CLOSING AGREEMENT AS TO FINAL DETERMINATION  
                         COVERING SPECIFIC TAX MATTERS  
                                         NJ Form 906  
   
 A request for a Closing Agreement to be made between  
   
 ________________________________________________                                ________________  
 (Name of Taxpayer)                                                              (Social Security #)  
 ______________________________________________________________________  
 (Address)  
 ________________________________________________            ________________  
 (and/or Corporation)                                                            (Federal ID #)  
          (If Corporation please provide a current financial statement)  
   
 ______________________________________________________________________  
 (Address)  
    
 ______________________________________________________________________  
 (Email Address)  
  
 for ____________________________________________________________________  
       (Type of Tax or Taxes and Outstanding Years/Periods)  
   
 and the Director of the Division of Taxation.  
   
 Please state below the reasons why the taxpayer feels they should not have to pay the total 
 outstanding tax liabilities due the Division of Taxation.  
   
  (If additional space is required you may attach an additional 
 sheet)   
 Amount Offered as Payment in Full: $_________________  
   
 How will payment be made? ________________________  
   
 Source of Funds for Offer: __________________________  
   
 ______________________________________                           _______________  
          Signature of Taxpayer/Officer                                    Date

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                         State of New Jersey Division of Taxation  
                                 Financial Statement of Debtor  
   
                                 Section I – Employment Data  
   
 1. __________________________________________    2.  ______________          3. _________________  
     Name (Debtor)                                         Birth Date         Social Security #  
   
 4. ______________________________________________________________ ___________________ 
     Home Address                                                         Phone Number  
   
 5. __________________________________________   6.  ______________           7. 
   _________________  
     Name (Spouse)                                         Birth Date         Social Security #  
       (Provide address if different from yours)  
   
                              DEBTOR EMPLOYMENT DATA  
 8. Occupation: ________________________    9. How Long in Present Employment? ___________  
   
 10. Present Employer’s Name: _______________________________________________________ 
       Address: ________________________________________  Phone Number________________  
   
 11. Present Monthly Income Total: $_______________(Provide breakdown on line below)  
       Salary or Wages $__________ Commissions $_________ Other (State Source) $_________  
       
 12. Other Employment – Within the last three years: 
 Employer’s Name        Address                             Phone Number     Employment Dates  
 ________________       _____________________________       _____________  ________________  
 ________________         _____________________________       _____________  ________________ 
 ________________         _____________________________       _____________  ________________  
   
                              SPOUSE’S EMPLOYMENT DATA  
 13. Occupation: ________________________  14. How Long in Present Employment? ___________  
   
 15. Present Employer’s Name: _______________________________________________________ 
       Address: ________________________________________ Phone Number________________  
   
 16. Present Monthly Income Total: $_______________(Provide breakdown on line below)  
       Salary or Wages $__________ Commissions $_________ Other (State Source) $_________  
   
 17. Other Employment – Within the last three years: 
 Employer’s Name        Address                             Phone Number     Employment Dates  
 ________________       _____________________________       _____________   _______________  
 ________________       _____________________________       _____________   _______________  
 ________________       _____________________________       _____________   _______________

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DEPENDENTS

18. Total Number: _______

Relationship __________ Age ___ Relationship __________ Age ___ Relationship _________ Age ___

19.Total Monthly Income of Dependents (except spouse): $_______________
Section II – Financial Data

20. For what period did you last file a Federal tax return? _________________________

21. For what period did you last file a New Jersey Income tax return? _______________

22. Amount of Gross Income reported on last Federal tax return filed? $_____________
Monthly Income and Expense Analysis

Total Income Gross Necessary Living Expenses Claimed

23. Wages/Salaries (Taxpayer) $ 34. National Standard Expenses (1) $

24. Wages/Salaries (Spouse) 35. Rent/ Mortgage

25. Interest / Dividends 36. Utilities

26. Net Business Income 37. Health Care

27. Rental Income 38. Taxes (Income) - Federal

28. Pension (Taxpayer) 39. Taxes (Income) – State

40. Property Taxes
29. Pension (Spouse)
(If not included with mortgage)

30. Child Support 41. Court Ordered Payments

31. Alimony 42. Child/Dependent Care

32. Other Income (Specify) 43. Other Expenses (Specify)

33. Total Income $ 44. Total Expenses $

(1) Select value from National Standard Expenses Table on last page of this application

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                       Section III – Assets and Liabilities  
                                    
 45. Cash                                            $ _____________  
   
 46. Checking Account                             _____________  
   
 47. Savings Account                        _____________  
   
 48. Stocks, Bonds & Other Securities             _____________  
   
 49. Cash or Loan Value of Insurance              _____________  
   
 50. Motor Vehicles (Model and Year)  
 a. Owned Vehicles   
 1. ____________________________   _____________  
 2. ____________________________   _____________  
 3. ____________________________   _____________  
 b. Leased Vehicles  
 1. ____________________________   _____________  
 2. ____________________________   _____________  
 3. ____________________________   _____________  
   
 51. Debts Owed to You                            _____________  
   
 52. Household Furniture and Goods          _____________  
   
 53. Items Used in Trade or Business              _____________  
   
 54. Real Estate  
     1. __________________________________        _____________  
     2. __________________________________        _____________  
     3. __________________________________        _____________  
     4. __________________________________        _____________  
   
 55. Any Other Assets - Specify  
 1. __________________________________   _____________  
 2. __________________________________   _____________  
 3. __________________________________   _____________  
 4. __________________________________   _____________  
   
                                 Total Assets          $ _____________

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                       Section III – Assets and Liabilities Continued  
                                                     
                                          Liabilities  
   
 56.    Bills Owed (Doctors, Lawyers, etc.)  
        1. __________________________________          $_____________  
        2. __________________________________            _____________  
        3. __________________________________   _____________         
   
 57.    Installment Debt (Car, Credit Card, etc.)  
        1. __________________________________   _____________         
        2. __________________________________   _____________         
        3. __________________________________   _____________         
        4. __________________________________   _____________         
        5. __________________________________   _____________         
   
 58.    Federal Taxes Owed                             _____________  
        Has Federal lien been filed? _________               
           (If yes please supply copy)  
   
 59.    State Taxes Owed                                   _____________  
   
 60.    Real Estate Mortgages (2)  
        1. __________________________________   _____________         
        2. __________________________________   _____________         
        3. __________________________________   _____________         
   
 61.    Loans Payable (To Banks, Finance Co., etc.) (2)  
        1. __________________________________   _____________         
        2. __________________________________   _____________         
        3. __________________________________   _____________         
   
 62.    Judgments Owed (Other Than Federal or State)     
        (Please supply copy)  
        1. __________________________________   _____________         
        2. __________________________________   _____________         
        3. __________________________________   _____________         
        
 63.    Other Debts (Itemize)  
        1. __________________________________   _____________         
        2. __________________________________   _____________         
        3. __________________________________   _____________         
   
                                   Total Liabilities      $ _____________  
   
 (2)  Note: Please include your current statement from lender with monthly payment amount and 
 current balance due.

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                       Section IV – General Financial Information  
     
   64.   Real Property (Brief description and type of ownership)  
        
         Physical Address                                         Date Acquired      Cost  
         ______________________________________                   _______________    ___________  
         ______________________________________                   _______________    ___________  
     ______________________________________      _______________                  ___________  
     ______________________________________      _______________                  ___________  
     
   65.   Bank Accounts (Include Savings and Loans, Credit Unions, IRAs & Retirement Plans, Certificate of Deposit, etc.)  
     
         Name of Institution   Address         Type                   Acct #         Balance  
         ________________      _________________ ___________ ___________ ___________  
         ________________      _________________ ___________ ___________ ___________  
         ________________      _________________ ___________ ___________ ___________  
                                                                                Total $  ___________  
     
   66.   Securities (Stocks, bonds, mutual funds, money market funds, government securities, etc.)  
     
         Kind                     Quantity     Owner of Record                    Current Value  
         _______________________ ___________ ________________   ________________  
         _______________________ ___________ ________________   ________________  
         _______________________ ___________ ________________   ________________  
         _______________________ ___________ ________________   ________________  
                                                                      Total $________________  
     
   67.   Charge Cards and lines of credit from banks, credit unions and savings and loans  
     
                                  Financial                       Credit     Amount  Monthly  
         Type of Account or Card  Institution                     Limit     Owed     Payment  
         ______________________   ________________   ______   __________ __________  
         ______________________   ________________   ______   __________ __________  
         ______________________   ________________   ______   __________ __________  
         ______________________   ________________   ______   __________ __________  
         ______________________   ________________   ______   __________ __________  
                                                                                  Total $__________  
     
   68.   Life Insurance                                                                                 
             
                                               Type                   Face           Available  
         Name of Company   Policy Number       Whole/Term Amount                     Loan Value  
         ________________   ________________   __________   ___________ ____________  
         ________________   ________________   __________   ___________ ____________  
         ________________   ________________   __________   ___________ ____________  
                                                                                                      
                                                                                 Total $____________

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                          Section V – General Information 

69. Are you a party in any lawsuit now pending?   ____ Yes ____No
    If yes please explain:

70. Are you a trustee, executor or administrator? ____ Yes ____No 
    If yes please explain:

71. Is anyone holding any monies on your behalf? ____ Yes ____No
    If yes please explain:

72. Is there any likelihood you would receive an inheritance? ____ Yes ____No
    If yes please explain:  

73. Do you receive or under any circumstances expect to receive benefits from an established 
    trust from a claim for compensation or damages from a contingent or future interest in 
    property of any kind? ____ Yes ____No
    If yes please explain:  

With knowledge of the penalties for false statements provided by 2C:21-4(b) ($7,500 fine and /or  3-
5 years imprisonment) and with the knowledge that this financial statement is submitted by me to 
affect action by the Division of Taxation, I certify that I believe the above statements are true and 
that it is a complete statement of all my income and assets, real and personal, whether held in my 
name or by any other.  

___________________         _____________________________________ 
Date                        Signature  
Revised 08/2004

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National Standards: Food, Clothing and Other Items

Disclaimer: IRS Collection Financial Standards are intended for use in calculating repayment of delinquent
taxes. These Standards are effective on March 25, 2019 for purposes of federal tax administration only.
Expense information for use in bankruptcy calculations can be found on the website for the U.S. Trustee
Program.

Download the national standards for food, clothing and other items in PDF format for printing. Please note
that the standard amounts change, so if you elect to print them, check back periodically to assure you have
the latest version.

National Standards have been established for five necessary expenses: food, housekeeping supplies, apparel
and services, personal care products and services, and miscellaneous.

The standards are derived from the Bureau of Labor Statistics (BLS) Consumer Expenditure Survey (CES)
and defined as follows:

Food includes food at home and food away from home. Food at home refers to the total expenditures for
food from grocery stores or other food stores. It excludes the purchase of nonfood items. Food away from
home includes all meals and snacks, including tips, at fast-food, take-out, delivery and full-service
restaurants, etc.

Housekeeping supplies includes laundry and cleaning supplies, stationery supplies, postage, delivery
services, miscellaneous household products, and lawn and garden supplies.

Apparel and services includes clothing, footwear, material, patterns and notions for making clothes,
alterations and repairs, clothing rental, clothing storage, dry cleaning and sent-out laundry, watches, jewelry
and repairs to watches and jewelry.

Personal care products and services includes products for the hair, oral hygiene products, shaving needs,
cosmetics and bath products, electric personal care appliances, and other personal care products.

The miscellaneous allowance is for expenses taxpayers may incur that are not included in any other
allowable living expense items, or for any portion of expenses that exceed the Collection Financial Standards
and are not allowed under a deviation. Taxpayers can use the miscellaneous allowance to pay for expenses
that exceed the standards, or for other expenses such as credit card payments, bank fees and charges, reading
material and school supplies.

Taxpayers are allowed the total National Standards amount monthly for their family size, without
questioning the amounts they actually spend. If the amount claimed is more than the total allowed by the
National Standards for food, housekeeping supplies, apparel and services, and personal care products and
services, the taxpayer must provide documentation to substantiate those expenses are necessary living
expenses. Deviations from the standard amount are not allowed for miscellaneous expenses. Generally, the
total number of persons allowed for National Standards should be the same as those allowed as dependents
on the taxpayer’s most recent year income tax return.

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Expense                 One    Two       Three   Four 
                        Person Persons   Persons Persons 

Expense                 $386   $685      $786    $958 

Housekeeping            $40    $72       $76     $76 
supplies 

Apparel & services      $88    $159      $169    $243 

Personal care           $43    $70       $76     $91 
products & services 

Miscellaneous           $170   $302      $339    $418 

                        $727   $1,288    $1,446  1,786 
Total 

More than four persons                   Additional Persons 
                                         Amount 

For each additional person, add to four- $420 
person total allowance:

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