(For Official Use Only)
A-3730-UEZ                           State of New Jersey
(Rev. 02/12)                    DIVISION OF TAXATION                                 CLAIM # U

      SALES & USE TAX CLAIM FOR REFUND - URBAN ENTERPRISE ZONE BUSINESSES
                   For Property and Services Used Exclusively Within a Qualified Zone(s)
SECTION ONE                                                                3. FOR DIVISION USE ONLY -
1. BUSINESS NAME:

2. IDENTIFICATION NUMBER:

CHECK TO BE MAILED TO:                                                     5. UEZ PERMIT NUMBER:
4. ATTENTION OF:                                                           6. PERIOD FOR WHICH CLAIM IS MADE:

ADDRESS:                                                                   Beginning:

                                                                           Ending:

CITY:                                                                      7. TOTAL REFUND REQUESTED:

STATE:                          ZIP:                                          $
SECTION TWO 
INDICATE METHOD OF SUBMISSION (placing an "X" in the box to the left).

           ELECTRONIC Spreadsheet (A-3730-UEZ-1) is required to be submitted on compact disc for claims 
1          with 25 or more transactions.                                   

           MANUAL Spreadsheet (A-3730-UEZ-1) is substituted for the electronic spreadsheet for claims with 25 
2          or less transactions.
SECTION THREE
AFFIRMATION: This claim contains only purchases of property and/or services used exclusively at my business location within 
an Urban Enterprise Zone(s), the information submitted is true and accurate, and the underlying documentation will be retained 
for a period of no less than 4 years from the postmark date of this claim and will be made available to the Division of Taxation 
upon request.  Further more, I  understand the Division of Taxation reserves the right to audit this claim within the statutory 
period (4 years).  I declare under the penalties of perjury that this claim (including any accompanying schedules and statements) 
has been examined and to the best of my knowledge and belief is true and correct.

8.SIGNATURE OF AUTHORIZED INDIVIDUAL SUBMITTING CLAIM:                     10. DATE OF SIGNATURE:

                                                                                                /                  /
9. PRINT - Name & Title of Signing Officer/Owner/Representative            11. TELEPHONE #

                                                                           (         )                             EXTENSION

                                     12. E-MAIL ADDRESS:
  Along with this completed claim form submit the required spreadsheet (Form A-3730-UEZ-1), and a Use Tax Accrual Schedule
           (if applicable), and when required a fully completed Appointment of Taxpayer Representative (Form M-5008-R)
                                (See INSTRUCTION pages for all details & address.)