Rev. 9/2018
New Jersey Division of Taxation
Identity Theft Declaration
Complete and submit this form if you are an actual or potential victim of identity theft and you would like the New Jersey Division of
Taxation to mark your account to identify any questionable activity
Mark an X in one of the following boxes:
I am a victim of identity theft and it is affecting my New Jersey State tax record.
I have experienced an event involving my personal information that may at some future time affect my NJ State tax
records. (Mark this box if you are the victim of non-tax-related identity theft or at risk due to a lost/stolen wallet or purse,
questionable credit card or report activity, etc.)
Briefly describe the problem and how you were made aware of it.
Taxpayer’s Last Name
First Name
M. I.
Social Security Number
Taxpayer’s Current Mailing Address (number and street with apt. or suite no., or PO Box )
Daytime Telephone #
Tax Year(s) Affected
Filing Status and Tax year of Last
New Jersey Tax Return Filed
Paid Tax Preparer Name (if any)
Preparer’s PTIN
Address on Last New Jersey Tax Return Filed
Zip Code
Under penalty of perjury, I declare that, to the best of my knowledge and belief, the information entered on this form is true, correct, complete, and
made in good faith.
Signature of Taxpayer
Printed Name of Person Signing Date Signed
Submit this completed form and a photocopy of one of the following documents to verify your identity:
a) Driver’s license
b) U.S. passport
c) U.S. military ID card
d) Other valid ID issued by a state or federal agency
Include photocopies of the following (If applicable):
Police Report Statement or FTC Identity Theft Report.
Proof of address for tax year(s) affected or, if not applicable, your current address (or utility bill, lease agreement, bank
statement, etc.)
Notice received from the NJ Division of Taxation .
Send photocopies of any of the above items along with this form to:
NJ Division of Taxation
Attn: Identity Theft
PO Box 272
Trenton, NJ 08695-0272