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Get NJ Annual Verification Form (For MBE/WBE Only)

The State of New Jersey Print Form Department of the Treasury Division of Revenue ANNUAL VERIFICATION FORM FOR MBE/WBE ONLY Must be submitted at the end of years 1 2 of a 3-year Certificate Period Our records indicate that you were issued a Minority and/or Women Business Enterprise M/WBE certificate with our Division. To maintain your certificate in an active status you must submit a completed annual verification form to indicate any changes in your company s ownership status and to provide your company s updated contact information. Note The Division reserves the right to request two years of business federal and state tax returns including all schedules and most recent income statements and balance sheets. Please check here if business ownership has not changed since your certification date. If any information is incorrect please provide corrections and attach the documentation* Certificate Number Company Name Address City State County Zip E-Mail Phone Fax Owner s Name I do herewith attest that the ownership and Owner Partner or President only control of under Business Name Federal Identification/S*S* Number on which the original certification was granted has not changed during the last twelve 12 months. If changed please attach documentation Owner Signature Date Notary Return to NJ Division of Revenue Business Support Services PO Box 455 Trenton NJ 08646 1 Updated contact information including e-mail address is essential to ensuring receipt of annual verification and end-of-certification period notices from the Division s NJSAVI system*. Please check here if business ownership has not changed since your certification date. If any information is incorrect please provide corrections and attach the documentation* Certificate Number Company Name Address City State County Zip E-Mail Phone Fax Owner s Name I do herewith attest that the ownership and Owner Partner or President only control of under Business Name Federal Identification/S*S* Number on which the original certification was granted has not changed during the last twelve 12 months. If changed please attach documentation Owner Signature Date Notary Return to NJ Division of Revenue Business Support Services PO Box 455 Trenton NJ 08646 1 Updated contact information including e-mail address is essential to ensuring receipt of annual verification and end-of-certification period notices from the Division s NJSAVI system*. .

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