Gtb 10 Form – Fill Out and Use This PDF

Application for Tax Clearance – Business Assistance and Incentives

This form is not for business dissolutions.

Use this form if you need a tax clearance certificate for a grant, loan, loan guarantee, rebate, tax credit, or other monetary incentive issued by a New Jersey agency or authority. If the applicant has not filed or paid all required tax obligations, the Division of Taxation will not issue a tax clearance certificate. However, the Division will notify the applicant of what needs to be resolved in order to have a tax clearance certificate issued.

Applicant Information:

Legal Name of Applicant:

Trade Name of Applicant:

Business Location or Home Address:

Mailing Address for Tax Clearance Certificate:

(If different from Business Location or Home Address)

NJ Tax Registration #:	EIN/SSN

Agency Issuing Assistance/Incentive:

(This information is required to process this application.)

Name of Agency:

Name of Assistance/Incentive Program:

Agency Contact Person:

Agency Contact Phone #:

Agency Contact Email:

I certify that I am authorized to complete this tax clearance application. I affirm that the information provided herein is true and complete, and that I will be held personally liable under penalties of perjury for making any false statements. (N.J.S.A. 2C:28-1)

Iunderstand that the Division of Taxation may communicate to the issuer State agency, the status of the tax compliance of the applicant. By signing this tax clearance application, I consent to the release of such general status information by the Division of Taxation.

Signature of Authorized Representative:

Print Name:	Title:
Contact Phone #:	Date:
Email Address:

We will not process this application if you do not provide a contact phone number and/or email.

List of Officers, Partners or Members: (Attach additional sheets if necessary)

Name	SSN:
Address:
Name	SSN:
Address:
Name	SSN:
Address:

Parent Company, Subsidiary, or other Related Entity That Will Directly Benefit From This Assistance:

(Attach additional sheets if necessary)

Name:	Taxpayer ID #:
Address:
Relationship:	Type of Business:
Name:	Taxpayer ID #:
Address:
Relationship:	Type of Business:
P.L. 2007,c. 101 established a tax clearance	program for awards of certain business assistance and incentive programs, including but not limited to

a grant, loan, loan guarantee, or other monetary or financial benefit issued by New Jersey and its independent agencies and authorities to assist in the conduct or operation of a business, occupation, trade, or profession in New Jersey. As a precondition to, or as a component of, the application process, the applicant must provide to the State agency a current tax clearance certificate issued by the Director of the Division of Taxation.

Mandatory Application Fees:

Standard Processing - $75.00

Expedited Processing (response within three (3) business days) - $200.00.

Payment must be made by check or money order payable to the “New Jersey Division of Taxation”.

The fee is non-refundable and entitles the applicant to updated tax clearance certificates for up to one year from the date of application.

Mail this application and fee to:

State of New Jersey

Division of Taxation

Business Assistance Tax Clearance Unit

3 John Fitch Way – 8th Floor

P.O. Box 272

Trenton, NJ 08695-0272

Questions about the tax clearance process may be directed to: (609) 322-6835 or email

BusinessAssistanceTC.Taxation@treas.nj.gov .

All other questions should be directed to the agency providing the assistance/incentive.