Fill and Sign the Application Instructionschecklist New Jersey Division of Form

TAX COURT OF NEW JERSEY CERTIFICATION OF INDIGENCY Please complete this form by answering all questions and providing as much information as possible. Forward the completed document to the Tax Court Management Office, P.O. Box 972, Trenton, NJ 0862 5 Name Address Plaintiff , v. Defendant. CIVIL ACTION CERTIFICATE OF INDIGENCY I, , of full age do hereby certify as follows: 1. I am the plaintiff in the above entitled action. 2. I reside at . 3. I make this certification in support of my application for waiver of fees pursuant to Rule 1:13-2(a). 4. My net income is $ per month, derived from employment at . 5. The following is a true and complete listing of my asset s, to the best of my knowledge, information and belief: a. Money in any and all bank accounts: . b. Automobile(s): . c. Real Estate: . d. Insurance with cash value: . e. Money owed to me: . 6. This certification is made to inform the Court as to my st atus of indigency and support my application for waiver of fees in the above entitled action pursuant to Rule 1:13-2(a). I 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. Signature Date Revised 7/2007, CN 11015-English page 1 of 1