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This is a New Jersey form that can be used for Civil Division within Statewide.
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Save NOTICE: This is a public document, which means the document as submitted will be available to the public upon request. Therefore, do not enter personal identifiers on it, such as Social Security number, driver's license number, vehicle plate number, insurance policy number, active financial account number, or active credit card number. YOU MUST COMPLETE THIS PART: Filing Attorney Information or Landlord: Name NJ Attorney ID Number Address Telephone Number , Plaintiff, v. , Defendant. Superior Court of New Jersey Law Division, Special Civil Part County Landlord-Tenant Division Docket Number: LT Civil Action Certification by Landlord The landlord should complete Part A or Part B or both (if both apply). Cross out any paragraphs in those parts that do not apply in this case. Part C applies to all cases and must be completed. A. When the Eviction is Based on Unpaid Rent 1. The tenant has failed to pay rent now due and owing in the amount of $ . That amount consists of basic rent of $ , late charges of $ , legal fees relating to this action for eviction of $ , filing fees and costs of $ , and other (specify) . 2. All of the items listed above are included in the lease agreement as rent. 3. All of those items are permitted by applicable federal, state and local laws (including rent control or rent leveling, if applicable) to be charged as rent for purposes of this action. B. When the Eviction is Based on Other Grounds Eviction is sought because: C. In All Cases 1. I have attached a copy of all notices that have been served on the tenant. 2. These notices were served on the tenant (select all that apply) 3. 4. 5. 6. 7. by ordinary mail, by certified mail, personally, on . All of the facts stated in the notices are true. If I proceeded without an attorney, I certify that I own the property in my own name or in the name of a general partnership of which I am a partner. I have complied with the registration requirements of N.J.S.A. 46:8-27 et seq. The tenant did not transfer ownership to me and I have not given the tenant an option to buy the property. The tenant is not in the military service of the United State nor any of its allies, nor is the premises used for dwelling purposes of the spouse, a child or other dependent of a person in the military service of the United States. I, the landlord, 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: Landlord Signature Print Name Revised 9/1/2008, CN 10512-English (Appendix XI-T - Certification by Landlord) American LegalNet, Inc. www.FormsWorkFlow.com