APPENDIX XI-T — CERTIFICATION BY LANDLORD
YOU MUST COMPLETE THIS PART:
NAME OF LANDLORD OR ATTORNEY: ________________________________
ADDRESS & PHONE #: ______________________________________________
_______________________________________________________
Plaintiff,
vs.
Defendant.
SUPERIOR COURT OF NEW JERSEY
LAW DIVISION
SPECIAL CIVIL PART
_____________ COUNTY
LANDLORD-TENANT DIVISION
Docket No. 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 (check one or more) _____ by ordinary mail, _____ by certified mail,
_____ personally, on _____________________________________________________________________.
3. All of the facts stated in the notices are true.
4. 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.
5. I have complied with the registration requirements of N.J.S.A. 46:8-27 et seq.
6. The tenant did not transfer ownership to me and I have not given the tenant an option to buy the property.
7. 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 WILFULLY
FALSE, I AM SUBJECT TO PUNISHMENT.
DATE: _______________ ___________________________________________________________
(PRINT NAME BELOW) LANDLORD
[Note: Appendix XI-T adopted July 18, 2001 to be effective November 1, 2001; amended July 27, 2006 to be
effective September 1, 2006, amended July 9, 2008 to be effective September 1, 2008.]
