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A-5088-TC Application For Tax Clearance Certificate
State of New Jersey
4-22 Department of the Treasury
Division of Taxation
PO Box 269
Trenton, NJ 08695-0269
($25 application fee)
To the Director of the Division of Taxation, Department of the Treasury, State of New Jersey:
Application is hereby made by
(Name and address of corporation)
for a Tax Clearance Certificate under Title 54 of the Revised Statutes.
Correspondence and eventual issuance of Tax Clearance Certificate should be addressed to:
(if third party, authorization letter must be included) (Phone Number)
NJ Corporation Number FID Number
State and date of incorporation or authorization
Note: All questions must be answered.
1. The purpose for which Certificate is to be used is (state whether for dissolution, merger, withdrawal, or reauthorization) and the
intended effective date of noted action
2. The accounting year employed by the corporation for federal income tax purposes is
(See special instructions)
3. Is this entity part of an affiliated group? Yes or No
a. If “Yes,” is the total payroll for the whole group over $5,000,000? Yes or No
4. Is the entity/corporation currently a member of a combined group filing a combined New Jersey Corporation Business Tax return? Yes or No
If “Yes,” provide:
Name of the combined group’s managerial member
Combined group NU identification number NU
By providing this information you are attesting that no separate entity CBT return needs to be filed and no estimated CBT payment needs to be
made by the corporation. Any CBT liability for the dissolved or withdrawing corporation will be paid by the managerial member of the combined
group.
5. Have any of the assets of the corporation been sold or transferred during the current or prior taxable accounting period? Yes or No
If “Yes,” enter:
a. Date sold
b. Sales price or fair market value of assets $
c. Profit on sale or transfer of assets $
d. Sales price of real estate included in the above $
e. Profit on sale or transfer of such real estate $
f. Name of purchaser or transferee of real estate and other assets
6. Have any of the assets of the corporation been distributed in dissolution or liquidation during the current or prior taxable accounting periods?
Yes or No If “Yes,” give names, dates, and other particulars .
7. Has the corporation or its stockholders entered into any negotiations or contract for the sale of any of the remaining assets?
Yes or No If “Yes,” state the full consideration to be received $
8. Have any dividends been declared or payments made in liquidation of capital stock? Yes or No
If “Yes,” give amounts, dates, and other particulars
9. If all the assets have not been disposed of, advise:
a. What disposition will be made of remaining assets?
b. Fair market value of assets remaining to be liquidated $
10. Who will continue the business formerly conducted by this corporation?
11. Give names and addresses of the present officers and directors of the company
Enclosed is remittance in the sum of $25 made payable to the State of New Jersey. (See important note below).
I declare and affirm, under the penalties provided by law, that this application (including any accompanying statements) has been examined by me and
the statements contained therein are true to the best of my information, knowledge, and belief.
Date Signature of Officer
President, Vice President, Secretary, or Treasurer (Strike out Titles not applicable)
IMPORTANT NOTE: Corporations wishing to dissolve/withdraw may file dissolution documents online by visiting www.nj.gov/njbgs.
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