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Identity Theft Declaration
 

Mark an X in one of the following boxes:
 

Briefly describe the problem and how you were made aware of it.
Taxpayer First Name:   
Taxpayer Middle Initial:
Taxpayer Last Name: 
SSN:    
Address: 
City: 
State: 
Zip:   
Phone Number:   
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:  
 
Printed Name Signature:  
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).
 
     
 
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