The State of New Jersey
Department of the Treasury
Division of Revenue
ANNUAL VERIFICATION FORM (FOR MBE/WBE ONLY)
(Must be submitted at the end of years 1 & 2 of a 3-year Certificate Period)
Our records indicate that you were issued a Minority and/or Women Business Enterprise (M/WBE) certificate with our
Division. To maintain your certificate in an active status, you must submit a completed annual verification form to
indicate any changes in your company's ownership status and to provide your company's updated contact information.
Note:
The Division reserves the right to request two years of business federal and state tax returns including all schedules,
and most recent income statements and balance sheets.
Please check here if business ownership has not changed since your certification date. If any information is
incorrect, please provide corrections and attach the documentation.
Certificate Number:
Company Name:
Address:
City State: Zip:
County: E-Mail:
Phone: Fax:
Owner's Name:
I, , do herewith attest that the ownership and
control of , under
Federal Identification/S.S. Number
, on which the original certification was
(Business Name)
(Owner, Partner or President only)
granted, has not changed during the last twelve (12) months. (If changed please attach documentation)
Owner Signature
Notary
Date
Date
Return to: NJ Division of Revenue, Business Support Services, PO Box 455, Trenton, NJ 08646
1 Updated contact information including e-mail address is essential to ensuring receipt of annual verification and end-of-certification
period notices from the Division's (NJSAVI) system.
