FORM A-1CANDIDATE - SWORN STATEMENTNEW JERSEY ELECTION LAW ENFORCEMENT COMMISSION P.O. Box 185, Trenton, NJ 08625-0185 Phone: (609) 292-8700Website: www.elec.nj.govCandidate NameOffice SoughtCandidate Committee NameStreet AddressCityStateZip Code*Day Telephone*Evening TelephoneCommittee Email (Optional)Committee Website (Optional)Election DateElection Type: (Select One)CountyLegal Name of Election District or MunicipalityPolitical PartyI, the undersigned, do hereby certify as follows:1. The total amount expended or to be expended on behalf of my candidacy by me or by any other candidate, person, or committee shall be zero, or shall not, in the aggregate, exceed $5,800 for this election.2. I am aware that in the event the total amount expended or to be expended on behalf of my candidacy by me or by any other candidate, person or committee shall, in the aggregate, exceed $5,800, I am required to file the Form R-1 (Report of Contributions and Expenditures) through ELEC eFile, on each subsequent reporting date.3. I am aware that if I receive a contribution in excess of $200 in the aggregate from one source in an election or a currency (cash) contribution in any amount, I am required to report the contribution to the Commission on Form C-1 (Supplemental Contributor Information). I am aware that I am required to identify the source and the aggregate total of the contributions therefrom, and if the contributor is an individual, his/her occupation and the name and address of his/her employer.4. I am aware that contributions received in excess of $200 in the aggregate from one source starting with the 13th day before the election, up to and including the 8th day before the election must be reported to the Commission within 72 hours of receipt, and starting with the 7th day before the election, up to and including, the day of the election, must be reported to the Commission within 24 hours of receipt. I am aware that I am required to identify the source and the aggregate total of the contributions therefrom during the period, and if the contributor is an individual, his/her occupation and the name and address of his/her employer on Form C-1 (Supplemental Contributor Information).5. I am aware that if I make, incur or authorize an expenditure of money or other thing of value in excess of $200 in the aggregate to support or defeat a candidate or public question, starting with the 13th day before the election, up to and including the 8th day before the election, it must be reported to the Commission within 72 hours, and starting with the 7th day before the election, up to and including, the day of the election, it must be reported to the Commission within 24 hours on Form E-1 (Supplemental Expenditure Information).6. I am aware that I am required to designate a campaign treasurer and depository by filing Form D-1 (Certificate of Organization and Designation of Campaign Treasurer and Depository) with the Commission no later than 10 days after receipt of any contribution or no later than 10 days after making any expenditure, whichever comes first.CANDIDATE CERTIFICATION :I certify that the statements on this document are true.I am aware that if any of thestatements are willfully false, I may be subject to punishment.Registration NumberPINCandidateDate*Leave this field blank if your telephone number is unlisted. Pursuant to N.J.S.A. 47:1A-1.1, an unlisted telephone number is not a public record and must not be provided on this form.New Jersey Election Law Enforcement CommissionPage 1 of 1sForm A-1 Revised Jul 2023




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