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 
                          th
                          9  Floor 
                          PO Box 245 
                          Trenton, NJ 08695-0245 
 

                                      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. 
          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. 
 

Form M-5008-R (2-12)       State of New Jersey Division of Taxation                              Page 1 of 2 
                                                                
          APPOINTMENT OF TAXPAYER REPRESENTATIVE 
                                                         (TYPE OR PRINT) 
 
1.  Taxpayer Information (if matter involves a joint income return, enter both names 
if joint representation is requested). 
 
   Trusts:    Enter the name and EIN of the trust, name and address of the trustee. 
    Estates:  Enter the name and EIN of the estate, name and address of the executor or administrator. 
Taxpayer’s Name                                                Social Security number 
                                                                
Spouse’s/CU Partner’s  Name                                    Social Security number 
                                                                
Mailing Address                                                NJ Taxpayer ID number (if other than SS#) 
 
City                                                           Name and Address of Trustee or Executor 
 
State                                                Zip 
 Taxpayer is: 
□ Individual (for an income or individual use tax return filed by that individual, or a joint income tax return 
filed by the individual and his/her spouse/cu partner). 
□ Corporation           □ Partnership                           □ Sole Proprietorship      
□ Estate                □ Limited Liability Company             □ Trust (other than a business trust)  
□ Other:  ___________ 
 
2.  Representative Information (representative(s) must date and sign on page 2). 
The taxpayer(s) named above hereby appoints the  person(s)  named below as  his/her/their taxpayer 
representative. 
 
Name and Address                                               Telephone Number: 
                                                               Fax Number: 
                                                               Representative  ID: 
Name and Address                                               Telephone Number: 
                                                               Fax Number: 
                                                               Representative ID: 
To represent the taxpayer(s) before the State for the following tax matter(s): 
 
3.  Tax Matters 
□  All tax matters 
□  Specific tax matters listed below: 
Type of Tax (NJ Gross Income, Sales and Use, Corporate Business,            Year(s) & Period(s) 
Employment, etc.) 
  
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 could do or perform .The authority does not include the power to endorse a 
refund check. 
 
_________________________________                        __________________ __________________________
Taxpayer Signature                                       Date               Title (if applicable)
 
_________________________________                        __________________ __________________________
Taxpayer Signature                                       Date               Title (if applicable)
 

 Form M-5008—R (2-12)          Page 2 of 2 
 
 Taxpayer Name: ___________________________________  SS # ____________________        
  
 5.  Notices and Communications.  Original notices and other written communications will be sent 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 do not want any notices or communications sent to my representative(s). 
       □ The second representative listed in section 2 should also receive a copy of notices   
       and/or communications (other than automated computer notices). 
  
 6.  Retention/Revocation of Prior Appointment(s) or Power(s).  The filing of this 
 Appointment  of Taxpayer Representative automatically revokes all earlier Appointment(s) of Taxpayer 
 Representative and/or Power(s) of Attorney on file with the Division of Taxation for the same tax matters and 
 years or periods covered by this document unless the box below is checked. 
  
       □ Check here if you do not want to revoke any prior Appointment(s) of Taxpayer Representative 
       or Power(s) of Attorney.  Attach copies of previous Appointment or Power that you do not want to 
       revoke.
  
 7.   Signature of Taxpayer(s).  If  a  tax  matter concerns a joint return, both primary  and 
 spouse/cu partner must sign below if joint representation is requested.  If signed by a corporate officer, 
 partner, guardian, tax matters partner, executor, administrator, or trustee on behalf of the taxpayer, I 
 certify that I 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. 
 I/We declare under penalty of law that I/We have examined this document and that all information 
 included is true and correct to the best of my/our knowledge, information and belief. 
  
 _________________________________         __________________  __________________________
 Taxpayer Signature                        Date                Title (if applicable)
  
 _________________________________ 
 Print Name 
  
 _________________________________         __________________  __________________________
 Taxpayer Signature                        Date                Title (if applicable)
  
 _________________________________ 
 Print Name 
  
 8.  Acceptance of  Representation and Sample Signature.        
  
 I/We hereby accept appointment as representative(s) for taxpayer(s) who has/have executed this 
 Appointment of Taxpayer Representative. 
  
 _________________________________         __________________  __________________________
 Representative Signature                  Date                Title (if applicable)
  
 _________________________________ 
 Print Name 
  
 _________________________________         __________________  __________________________
 Representative Signature                  Date                Title (if applicable)
  
 _________________________________ 
 Print Name 
  

                                                                   Page 1 of 2 
                                                                                             (2--12) 
                      STATE OF NEW JERSEY – DIVISION OF TAXATION 
                           INSTRUCTIONS FOR FORM M-5008-R 
                      APPOINTMENT OF TAXPAYER REPRESENTATIVE 
 
Purposes of Form.  Form M-5008-R, Appointment of Taxpayer Representative, may be used to designate 
an individual(s) named as representative(s) and grants the representative(s) the authority to obligate, bind or 
appear on your behalf with respect to the tax matters listed in Section 3 of the Appointment of Taxpayer 
Representative Form.  This form may be used for all New Jersey taxes except those pertaining to Property 
Administration.  (Refer to Form M-5041). 
 
The representative(s) may be authorized to receive your confidential tax information.  Unless otherwise 
indicated, the representative(s) may also perform any and all acts that you can perform, including 
consenting to extend the time to assess  tax,  or executing consents that agree to  a tax adjustment.  
Representatives  may  not  sign  returns or delegate authority unless specifically  authorized on the 
Appointment of Taxpayer Representative. 
 
Note:   Authorizing someone to represent you  before the  Division  by  an Appointment  of Taxpayer 
        Representative does not relieve you of your tax responsibilities or obligations. It primarily allows 
        for representation by  others in most matters concerning tax administration, investigations, 
        examinations/audits  and  other forms of taxpayer conferences.  Since the obligation for tax 
        liabilities lies with the taxpayer, the authority granted to a representative may not extend through 
        certain aspects of the collection process to include, but not limited to judgments, levies, liens and 
        seizures. In those instances  the Division  may require telephone communication, direct contact 
        and/or interaction with the taxpayer. To the extent possible, however, the Division will make a 
        reasonable effort to honor authorized representation. Additionally, to protect the interests of the 
        taxpayer, the Division will contact the taxpayer directly when it has documentable instances of 
        unreasonable delays, incompetence or other forms of  malfeasance of the appointed taxpayer 
        representative. 
 
Form M-5008-R, Appointment of Taxpayer Representative, will not  be required  when an individual 
appears with the taxpayer or with an individual who is  authorized to  act on behalf  of taxpayer.  For 
example, Form M-5008-R is not required if an individual appears on behalf of a corporate taxpayer with an 
authorized corporate officer.   The Form is also not required if a trustee, receiver or attorney has been 
appointed  by a court  having  jurisdiction  over a  debtor.   In addition, the Form is not  required  if an 
individual merely furnishes tax information or prepares a report or return for the taxpayer. 
 
Fiduciaries.  A fiduciary (such as a trustee, receiver, or guardian) stands in the position of a taxpayer and 
acts as the taxpayer.   Therefore,  a fiduciary does  not  act as a representative and  should not  file an 
Appointment  of Taxpayer Representative.  However, if a fiduciary wishes to authorize an individual to 
represent or act on  behalf  of the  entity, an Appointment of Taxpayer  Representative  must be filed and 
signed by the fiduciary.  
 
Who Can Execute the Appointment of Taxpayer Representative? 
-  Any 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 separate Appointment of Taxpayer Representative. 
-  A member of a Limited Liability Company (LLC), if the taxpayer is an LLC and there is no manager; 
-  A manager of the LLC; 
-  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 has legal authority to bind 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).  

Form M-5008-R Instructions (2-12)                                                                 Page 2 of 2 
 
Tax Matters 
 
The  Appointment of Taxpayer Representative will apply to all tax types and taxable years or  privilege 
periods unless the taxpayer(s) designates otherwise. 
            
Retention/Revocation of Prior Powers of Attorney and/or Appointment of Taxpayer Representative 
 
You may not partially revoke a previously filed Appointment of Taxpayer Representative or  Power of 
Attorney. If a previously filed Appointment of Taxpayer Representative 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 Appointment of Taxpayer Representative indicating the representative(s) you want 
to retain. 
 
Taxpayer’s Signature 
 
Form M-5008-R must be signed  by the taxpayer or by an individual who is authorized to execute the 
Appointment of Taxpayer  Representative on  behalf  of the taxpayer.  The taxpayer  or  his/her  or its 
representative(s) may be required to  provide identification and evidence of authority to sign this 
Appointment of Taxpayer Representative. 
 
Individuals.  You must sign and date Form M-5008-R.  If a joint gross income tax return has been filed and 
both husband and wife/both cu partners will be represented by the same individual(s), both must sign Form 
M-5008-R unless one spouse/cu partner authorizes the other, in writing, to sign for both.  In that case, 
attach a copy of the authorization.  If, however, a joint income tax return has been filed and husband and 
wife/cu partners will be represented by different individuals, each taxpayer must execute his or her own 
Appointment of Taxpayer Representative on a separate Form M-5008-R. 
 
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 Appointment of Taxpayer Representative is 
executed on behalf of the partnership only, it  must be  signed by a partner authorized to act for  the 
partnership.  A partner is authorized to act in the name of the partnership if, under state law, the partner has 
authority to bind the partnership. 
 
Limited Liability Companies.  A member or manager must sign Form M-5008-R, or, if the Appointment of 
Taxpayer Representative is executed on behalf of the Limited Liability Company (LLC) only, it must be 
signed by any member or manager duly authorized to act for the LLC, who must certify that he or 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.  Include evidence  of the authority of the 
fiduciaries to act when filing Form M-5008-R. 
 
Estates.  The administrator or executor of an estate may sign on behalf of an estate. 
 
Trusts.  The trustee of a trust may execute the Appointment of Taxpayer Representative. 
 
Others.  Form M-5008-R must be signed by the taxpayer or by an individual having the authority to act in 
the name of the taxpayer. 
 
The signature of an individual(s) that is/are not the taxpayer(s) identified in Section 1 certifies that he or 
she has or they have the authority to act for the taxpayer(s).  This applies to a corporate officer, partner, 
guardian, tax matters partner, executor, administrator, or trustee acting on behalf of the taxpayer(s). 
 
You must indicate the date of execution on Form M-5008-R. 
 

                     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) 
 
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 
 

                   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 
________________  _____________________________             _____________   _______________ 
________________  _____________________________             _____________   _______________ 
________________  _____________________________             _____________   _______________ 
 
                                                 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 
     

                         Section III – Assets and Liabilities 
                                        
                                      Assets 
 
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           $ _____________ 
 

                     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. 
 

                    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 $____________ 
 

                      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 

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 April 1, 2013 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 exemptions on the taxpayer’s most recent year income tax return. 
Expense                           One Person     Two Persons      Three Persons    Four Persons
Food                                        $315        $556                  $645                      $777
Housekeeping supplies                       $30         $66                   $65                       $74
Apparel & services                          $88         $162                  $209                      $244
Personal care products & services           $34         $60                   $64                       $70
Miscellaneous                               $116        $209                  $251                      $300

Expense                One Person Two Persons                   Three Persons Four Persons
Total                  $583       $1,053                        $1,234        $1,465

More than four persons                                          Additional Persons Amount
For each additional person, add to four-person total allowance:               $281