Place label on form if all preprinted
information is correct. Otherwise, print or
type your name and address.
For Tax Year Jan.-Dec. 31, 2012, Or Other Tax Year Beginning ____________, 2012, Month Ending , 20
IMPORTANT! YOU MUST ENTER YOUR SSN(s). Fill in if application for Federal extension is enclosed or enter confirmation #________.
Your Social Security Number Last Name, First Name and Initial
(Joint filers enter first name and initial of each - Enter spouse/CU partner
last name ONLY if different)
Spouse’s/CU Partner’s Social Security Number Home Address
(Number and Street, including apartment number or rural route)
County/Municipality Code (See Table p. 50) City, Town, Post Office State Zip Code
Do you wish to designate $1 of your taxes for this fund? Yes No
If joint return, does your spouse/CU partner wish to designate $1? Yes No
NJ-1040
2012
STATE OF NEW JERSEY
INCOME TAX-RESIDENT RETURN
5R
For Privacy Act Notification, See Instructions
- -
FILING STATUSDEPENDENTS
ENTER
NUMBERS
HERE
6
7
8
9
10
11
12a
12b
NJ RESIDENCY
STATUS
If you were a New Jersey resident for
ONLY part of the taxable year, give the
period of New Jersey residency:
From To
M M D D Y Y M M D D Y Y
// //
GUBERNATORIAL
ELECTIONS FUND
Note: if you fill in the Yes
oval(s), it will not increase your
tax or reduce your refund.
- -
Spouse/
Domestic
6. Regular Yourself
CU Partner
Partner
7. Age 65 or Over Yourself Spouse/CU Partner
8. Blind or Disabled Yourself Spouse/CU Partner
9. Number of your qualified dependent children .......................
10. Number of other dependents ........................................
11. Dependents attending colleges (See instr. page 16) ............
12. Totals
(For Line 12a - Add Lines 6, 7, 8, and 11)
(For Line 12b - Add Lines 9 and 10) .....................................
EXEMPTIONS
(Fill in only one)
1. Single
2. Married/CU Couple, filing
joint return
3. Married/CU Partner, filing separate
return. Enter Spouse’s/CU Partner’s
Social Security Number in the
boxes above
4. Head of household
5. Qualifying widow(er)/
Surviving CU Partner
13. Dependent’s Last Name, Dependent’s Social Security Number Birth Year
First Name, Middle Initial
a
b
c
d
--
--
--
--
Pay amount on Line 56 in full.
Write Social Security number(s) on
check or money order and make
payable to:
STATE OF NEW JERSEY - TGI
Mail your check or money order
with your NJ-1040V payment
voucher and your return to:
NJ Division of Taxation
Revenue Processing Center
PO Box 111
Trenton, NJ 08646-0111
IF REFUND:
NJ Division of Taxation
Revenue Processing Center
PO Box 555
Trenton, NJ 08646-0555
You may also pay by e-check or
credit card. See instruction page
11.
Division
Use
1
2 3 4 5 6 7
If you do not need forms mailed to you next year, fill in (See instruction page 14) ............................
I authorize the Division of Taxation to discuss my return and enclosures with my preparer (below) .........
Paid Preparer’s Signature Federal Identification Number
Firm’s Name Federal Employer Identification Number
_________________________________________________________________________________________________________________________________
Your Signature Date
If enclosing copy of death certificate for deceased taxpayer, fill in (See instruction page 12)
. . . . . . . . .
_________________________________________________________________________________________________________________________________
Spouse’s/CU Partner’s Signature (if filing jointly, BOTH must sign) Date
Fill in oval if dependent does
not have health insurance
including NJ FamilyCare/
Medicaid, Medicare, private or
other (see instructions)
Under the penalties of perjury, I declare that I have examined this income tax return, including accompanying schedules and state-
ments, and to the best of my knowledge and belief, it is true, correct, and complete. If prepared by a person other than taxpayer, this
declaration is based on all information of which the preparer has any knowledge.
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