Certification And Registration For Individuals Contracting With State Agencies {REG-A}

REV 9/1/04 NJ-REG-A Certification and Registration for Individuals Contracting With Public Agencies OFFICIAL USE ONLY: DLN #: (P.L. 2004, Ch. 57) Instructions: State law requires all contractors and subcontractors with the State or other public sector entities to provide proof of registration witht h eDepartment of TreasuYryo. u may use this form to comply witht he lawi f you are ani ndividual withn o businesstax or employer obligationws ith the State of New Jersey and are not yet registered. Fill out the registration section and certification below and send the completed form to: NJ Division of Revenue Client Registration Bureau PO Box 252 Trenton, NJ 08646-0252 Please note that the registrants name listed in Section A must be the same as shown in the Certification, Section B. Type, machine print or hand print all information, except your signature. If you have or will have business tax or employer obligations, file form NJ-REG. Call (609) 292-1730 for more information. SECTION A, REGISTRATION DETAIL FOR STATE CONTRACTOR OR SU BCONTRACTOR Social Security Number Registrants Name *Physical Address: Street, City, State, Zip Do not use P.O Box County Mailing Address: Street, City, State, Zip Contact Information Telephone Number E-mail Address SECTION B, CERTIFICATION OF CONTRACTOR OR SUBCONTRACTOR I __________________________________ hereby certify that I am an individual having no business tax or employer obligations with the State of New Jersey. Further, I certify that any income that I derive from business activities with the State of New Jersey will be reported on my personal income tax return. I understand that pursuant to State law, if I knowingly report inaccurate of misleading information, I may be subject to penalties. Signed: __________________________ Date: _______________ Signature American LegalNet, Inc. www.USCourtForms.com