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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 08625 Name Address
Plaintiff, v.
CIVIL ACTION
CERTIFICATE OF INDIGENCY
Defendant.
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 assets, 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 status 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.
Date
Signature
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Revised 7/2007, CN 11015 English, Certification of Indigency