CERTIFICATION OF ELIGIBILITY TO CONTINUE RECEIPT OF
DISABLED VETERANS’ REAL PROPERTY TAX EXEMPTION
N.J.S.A. 54:4-3.30 et seq. N.J.A.C. 18:28-1.1 et seq.
IMPORTANT File this completed certification with your municipal assessor.
1. CLAIMANT NAME
_____________________________________________________________________________________
Name(s) of disabled veteran claimant owner (and spouse/civil union partner, as tenants by entirety, or domestic partner) or of
disabled veteran’s surviving spouse/surviving civil union partner/surviving domestic partner permanently residing in dwelling.
2. DWELLING LOCATION
_____________________________________________________________________________________
Street Address of above claimant owner's principal residence Phone #
_____________________________________________________________________________________
County Municipality
BLOCK _______________________________ LOT ________________________ QUALIFIER___________________
YES NO I am the Disabled Veteran exemption claimant and a legal resident of New Jersey
and I occupy the dwelling listed on this form as my principal place of residence.
YES NO I, as the Disabled Veteran exemption claimant, hold sole legal title, by fee simple
or life estate, as:
the sole owner or
the owner with my spouse as tenants by entirety or
the owner with my civil union partner as tenants by entirety or
the owner with my domestic partner or
the life tenant.
YES NO My wartime service-connected disability, as declared by the United States
Veterans’ Administration, remains 100% total and permanent.
YES NO I have not claimed, nor am I receiving any other Disabled Veterans’ Exemption under this act
(N.J.S.A. 54:4-3.30 et seq.) on any other property owned by me, or me and my spouse/civil
union partner/domestic partner and located in New Jersey.
YES NO I am receiving another disabled veterans’ exemption on Block ____________ Lot _________.
Property located at ____________________________________________________________.
Address
YES NO I am the New Jersey resident surviving spouse/surviving civil union partner/surviving domestic
partner of a totally and permanently disabled war veteran as specified in N.J.S.A. 54:4-3.30 et
seq. and N.J.A.C. 18:28-1.1 et seq.
YES NO I have not remarried nor entered into a new civil union/domestic partnership.
YES NO I, as the surviving spouse/surviving civil union partner/surviving domestic partner, solely own
the property and continue to reside in the dwelling as my principal residence.
I certify the above declarations are true to the best of my knowledge and belief and understand they will be considered as
if made under oath and subject to penalties for perjury if falsified.
____________________________________________________________________________________
Signature of veteran claimant (and spouse/civil union partner/domestic partner) Date
____________________________________________________________________________________
Signature of surviving spouse/surviving civil union partner/surviving domestic partner Date
OFFICIAL USE ONLY - Block___________________ Lot_________ Qual.______ Approved Disallowed
Assessor Date
Form COEDVSSE February 2007
