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 veteran claimant owner (and spouse, as tenants by entirety, or domestic partner) or of surviving spouse/surviving
domestic partner permanently residing in dwelling
2. DWELLING LOCATION
_____________________________________________________________________________________
Street Address of 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 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 domestic partner or
the life tenant.
YES NO My wartime service-connected disability, as declared by the United States
Veterans Administration, remains 100%.
YES NO I have not claimed, nor have I been granted 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/domestic partner and located in New Jersey.
YES NO I am the New Jersey resident surviving spouse/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. and I have not remarried or entered into a new partnership.
YES NO I, as the surviving spouse/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/domestic partner) Date
____________________________________________________________________________________
Signature of surviving spouse/domestic partner Date
OFFICIAL USE ONLY - Block___________ Lot_________ Qual.______ Approved Disallowed
Assessor Date
Form COEDVSSE December 2005
