FORM D-4CONTINUING POLITICAL COMMITTEE - REGISTRATION STATEMENT AND DESIGNATION OF ORGANIZATIONAL DEPOSITORYNEW JERSEY ELECTION LAW ENFORCEMENT COMMISSION P.O. Box 185, Trenton, NJ 08625-0185 (609) 292-8700 or Toll Free Within NJ 1-888-313-ELEC (3532) Website: www.elec.nj.govCommittee NameIdentifying Title or Acronym (Optional)Street AddressCityStateZip Code*Day Telephone*Evening TelephoneELEC Identification NumberCommittee EmailCommittee Website(Optional)(Optional)Committee TypeCountyMunicipalityPolitical Party, if anyType of Filing:1. Chairperson NameMailing AddressCityStateZip Code *Day Telephone *Evening TelephoneOccupationEmployer Name and Address2. Treasurer NameMailing AddressCityStateZip CodeResident Address, if different from mailing addressCityStateZip Code *Day Telephone *Evening TelephoneOccupationEmployer Name and Address3. Depository InformationName of Bank or DepositoryMailing AddressCityStateZip Code Day TelephoneAccount NameAccount Number*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 5sForm D-4 Revised Jun. 2021
3. Depository Information (continued)Name of Bank or DepositoryMailing AddressCityStateZip Code Day TelephoneAccount NameAccount Number4. LIST THE NAME(S), MAILING ADDRESS(ES) AND TELEPHONE NUMBER(S) OF ANY PERSON(S) AUTHORIZED TO SIGN CHECKS OR OTHERWISE MAKE TRANSACTIONSNameMailing AddressCityStateZip Code *Day Telephone *Evening TelephoneNameMailing AddressCityStateZip Code *Day Telephone *Evening TelephoneNameMailing AddressCityStateZip Code *Day Telephone *Evening Telephone5. General Organizational Category or Affiliation (Select One)6. List the names/mailing addresses of the persons (other than chairperson) or entities having direct or indirect control over the affairs of the continuing political committee. (This includes, but is not limited to persons in whose name or at whose direction or suggestion the committee solicits funds or makes contributions.)Name of Person or EntityOccupationMailing AddressEmployer NameCityEmployer Mailing AddressState, Zip CodeCity, State, Zip Code*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 2 of 5sForm D-4 Revised Jun. 2021
6. (Continued)Name of Person or EntityOccupationMailing AddressEmployer NameCityEmployer Mailing AddressState, Zip CodeCity, State, Zip Code7. List the names/mailing addresses of the persons or entities not already listed in question #6 who, directly or through an agent, participated in the initial organization of the continuing political committee.Name of Person or EntityOccupationMailing AddressEmployer NameCityEmployer Mailing AddressState, Zip CodeCity, State, Zip CodeName of Person or EntityOccupationMailing AddressEmployer NameCityEmployer Mailing AddressState, Zip CodeCity, State, Zip CodeName of Person or EntityOccupationMailing AddressEmployer NameCityEmployer Mailing AddressState, Zip CodeCity, State, Zip CodeName of Person or EntityOccupationMailing AddressEmployer NameCityEmployer Mailing AddressState, Zip CodeCity, State, Zip CodeNew Jersey Election Law Enforcement CommissionPage 3 of 5sForm D-4 Revised Jun. 2021
8. Describe the economic, political or other particular interests and objectives to be advanced by the continuing political committee.9. List the name and resident address of a New Jersey resident who has been designated by the continuing political committee as the agent of the continuing political committee to accept service of legal process.NameResident AddressCityStateZip Code10. Has any New Jersey candidate or officeholder (other than a federal candidate) established, authorized the establishment of, maintained or participated directly or indirectly in the management or control of this continuing political committee, or will any New Jersey candidate do so in the future?11. What is the total amount of money this continuing political committee estimates it will raise: (Please estimate to the best of your ability.) This calendar year?Next calendar year?12. How much of the total amount of money raised is expected to be spent for New Jersey election-related activity during: (Please estimate to the best of your ability.) This calendar year?Next calendar year?13. What percentage of the total amount of money raised will be used for New Jersey election-related activity during: (Please estimate to the best of your ability.) This calendar year?%Next calendar year?%14. Is making contributions to New Jersey candidates or committees, or otherwise engaging in New Jersy election-related activity expected to be a major purpose of this continuing political committee?New Jersey Election Law Enforcement CommissionPage 4 of 5sForm D-4 Revised Jun. 2021

15. Besides engaging in election-related activity, what other types of expenditures will be made by this continuing political committee?16. Will this continuing political committee solicit any of its funds from the public for New Jersey election-related activity:inside New Jerseyoutside New Jersey*both inside and outside New Jersey* If "both," what percentage of the funds are expected to be raised outside New Jersey?%17. Will this continuing political committee solicit contributions with the stated or principal purpose of making contributions to New Jersey candidates or committees?18. Does this continuing political committee file with the Federal Election Commission?19. Will this committee engage in only independent expenditure activity?TREASURER/CHAIRPERSON CERTIFICATIONI certify that the statements on this document are true and correct. I further certify that no candidate or officeholder has established, authorized the establishment of, maintained or participated directly or indirectly in the management or control of the Continuing Political Committee, and no candidate or officeholder shall be permitted to do so during the existence of the Continuing Political Committee. I am aware that if any of the statements are willfully false, I am subject to punishment.Registration NumberPINDateTreasurerRegistration NumberPINChairpersonDateNew Jersey Election Law Enforcement CommissionPage 5 of 5sForm D-4 Revised Jun. 2021


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