Gtb-10 (R5 – 10/10) Page 1
State of New Jersey
Division of Taxation
Business Assistance Clearance Section
50 Barrack Street – 9
P.O. Box 272
Trenton, NJ 08695-0272
Application Fee Required
Standard processing $75.00
Expedited processing (a response within 3 business days) $200.00
Legal Name of Applicant ________________________________________________________________
Trade Name of Applicant _______________________________________________________________
Business Location Address______________________________________________________________
Mailing Address for Clearance Certificate (If different from Business Location Address)
NJ Tax Registration # ___________________________ FID/TIN # ______________________________
Type of Business
List All Officers or Partners on page 2 of application.
Please list on page 2 of this application any parent company, subsidiary or other related entity that will
directly benefit from this assistance.
Name of Issuer State Agency ________________________________Due Date___________________
Name of Assistance Program________________________________ Application# ________________
Agency Contact Person ________________________________________________________________
Agency Contact Address _______________________________________________________________
Agency Contact Phone # ____________________ Agency Contact Fax # ________________________
Agency Contact Email _________________________________________________________________
I certify that I am autho rized to complete this tax clearance application; that it is true and complete; and
that if any informatio n contained in this tax clearan ce application is willfully false, I may be subje ct to
I understand that the Division of Taxation may communicate to the issuer Stat e agency, the status of th e
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 Title Date
________________________________________________ ________________________________________* Required*
Print Name Contact Phone Number
Gtb-10 (R5 – 10/10) Page 2
Name of Applicant _____________________________ NJ Tax Registration # __________________
Effective July 1, 2007, P.L. 2007, c. 101 established a tax cle arance program for a wards of certai n
business assistance and incentive programs, including but not limited to a grant, loan, loan guarantee, or
other monetary or financial benefit issued by the State and its independent agencies and authorities to
assist in the conduct or o peration of a business, occupation, trade, or profession in the State. As a
precondition to or as a component of t he application process, th e applicant must provide to the State
agency a current tax clearance certificate issued by the Director of the Division of Taxation.
This application form i s intended to provide the Division of Taxation with the necessary information to
conduct its research and determine if the applicant is compliant with New Jersey tax laws such that a tax
clearance certificate may be issued. If the Director determines that the applicant has not filed all required
tax returns and has not paid all tax, penalties, interest, or fees due, the Director shall issue a notice to the
applicant of the particulars to be resolved before a tax clearance certificate may be issued.
Effective March 1, 2009, a fee will be imposed for all Applications for Tax Clearance – Business
Assistance and Incentives. The application fee is $75.00 for standard processing. An expedited service
(response within three (3) business days) is available for $20 0.00. The fee is non -refundable and will
cover updates, if nee ded for this application, for up to one ye ar. Payment mu st be made by check or
money order payable to the “New Jersey Division of Taxation”.
All Applications must be mailed or hand delivered to the Taxation address.
Applications received without payment will not be processed.
Questions about the tax clearance process may be directed to: (609) 292-6400.
Questions about the award process should be directed to the specific State Agency noted on page 1.
The following information is required
to verify and/or update our records.
List of Officers or Partners:
Name Address Social Security #
Attach additional pages as necessary.
Information on related entities:
(Name, Address, Relationship, Taxpayer Identification Number & Type of Business)
I certify the information on this page is correct.
(Signature of Authorized Representative) (Date)