DEPARTMENT OF TREASURY

DIVISION OF TAXATION

WIC PROJECT

PO BOX 445

TRENTON, N. J. 08625-0445

WAIVER OF RIGHTS UNDER N.J.S.A. 54:50-8 AND

AUTHORIZATION FOR RELEASE OF TAX RETURN INFORMATION

TO DEPARTMENT OF HEALTH

This form to be completed by the WIC vendor.

_____________________________________________________________________________________________

Print Name of WIC Vendor:
Print Street Address:
Print Town:
Telephone Number:
Print Name of Contact Person:
and Title:
Tax Identification Number:

_____________________________________________________________________________________________

This undersigned hereby authorizes the Division of Taxation to release tax return information to the Department of Health (DOH) for the sole and exclusive purpose of administration of the responsibilities under Federal Public Law 108-265.

The Taxation data subject to release to DOH may include the name, address and business gross receipts for WIC vendors identified by DOH.

By signing this form, the undersigned releases the New Jersey Division of Taxation and its contractor from the obligation to maintain the confidentiality of tax return information under N.J.S.A. 54:50-8. The undersigned also waives all right to make any claim against the Division of Taxation and its contractor for the limited release of tax information to DOH.

The undersigned represents that he/she is authorized to sign this waiver on behalf of the vendor for the purpose set forth herein.

_____________________________________________________________________________________________

Print Name of Owner, Partner or Officer of Vendor and Title
Signature of Owner, Partner or Officer of Vendor and Title	Date

WIC-8

JUN 15

ewhite

2015-06-23

NJDOH