Revised 9/1/2008, CN 10512-English (Appendix XI-T - Certification by Landlord)
NOTICE: This is a public document, which means the document as submitted will be available to the public upon request. Therefore, do not enter
personal identifiers on it, such as Social Security number, driver’s license number, vehicle plate number, insurance policy number, active financial
account number, or active credit card number.
YOU MUST COMPLETE THIS PART: Filing Attorney Information or Landlord:
NJ Attorney ID Number
Telephone Number
Superior Court of New Jersey
Law Division, Special Civil Part
Landlord-Tenant Division
Docket Number: LT
Civil Action
Certification by Landlord
The landlord should complete Part A or Part B or both (if both apply). Cross out any paragraphs in those parts that do not
apply in this case. Part C applies to all cases and must be completed.
A. When the Eviction is Based on Unpaid Rent
The tenant has failed to pay rent now due and owing in the amount of $ . That amount consists of basic
rent of $ , late charges of $ , legal fees relating to this action for eviction of $ ,
filing fees and costs of $ , and other (specify) .
All of the items listed above are included in the lease agreement as rent.
All of those items are permitted by applicable federal, state and local laws (including rent control or rent leveling, if
applicable) to be charged as rent for purposes of this action.
B. When the Eviction is Based on Other Grounds
Eviction is sought because:
C. In All Cases
I have attached a copy of all notices that have been served on the tenant.
These notices were served on the tenant (select all that apply)
by ordinary mail,
by certified mail,
personally, on .
All of the facts stated in the notices are true.
If I proceeded without an attorney, I certify that I own the property in my own name or in the name of a general
partnership of which I am a partner.
I have complied with the registration requirements of N.J.S.A. 46:8-27 et seq.
The tenant did not transfer ownership to me and I have not given the tenant an option to buy the property.
The tenant is not in the military service of the United States nor any of its allies, nor is the premises used for dwelling
purposes of the spouse, a child or other dependent of a person in the military service of the United States.
I, the landlord, certify that the foregoing statements made by me are true. I am aware that if any of the foregoing
statements made
by me are willfully false, I am subject to punishment.
Landlord Signature
Print Name