NJ Division of Taxation

Identity Theft Declaration

Mark an X in one of the following boxes:

I am a victim of identity theft and it is affecting my New Jersey State tax record.
I have experienced an event involving my personal information that may at some future time affect my NJ State tax records. (Mark this box if you are the victim of a non-tax-related identity theft or at risk due to a lost/stolen wallet or purse, questionable credit card or report activity, etc.

Briefly describe the problem and how you were made aware of it.

Taxpayer First Name:
Taxpayer Middle Initial:
Taxpayer Last Name:
SSN:	SSN Number must be 9 or 12 digits
Address:
City:
State:
Zip:	Zip must be 5 digits
Phone Number:	Phone Number must be 7 or 10 digits
Tax(es) and Year(s):
Tax Year and Filing Status of Last NJ Tax Return Filed:

Address on Last NJ Tax Return:
Address:
City:
State:
Zip:	Last Tax Return Zip must be 5 digits
	By checking this box I am electronically declaring under the penalties of perjury that this claim (including any accompanying schedules and statements has been examined by me and to the best of my knowledge and belief is true and correct. Please click the Signature Checkbox.
Printed Name Signature:	Please type in Signature.
Date Signed:	Please type in Date Signed.
	Invalid Date Signed.

Please submit a copy of one of the following documents to verify your identity.
Click "Browse" to select Document(s) to upload.

Driver's License

US Passport

US Military ID Card

Other Valid ID Issued by State or Fed

You may also include copies of the following:
Click "Browse" to select Document(s) to upload.

Proof of address for tax year(s) affected or, if not applicable, your current address (or utility bill, lease agreement, bank statement, etc.)

Notice received from the NJ Division of Taxation (if applicable).