POLITICAL COMMITTEE -  FORM PCREGISTRATION STATEMENT AND DESIGNATION OF
CAMPAIGN TREASURER AND 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)
AmendmentWebsite: www.elec.nj.gov
Committee NameIdentifying Title or Acronym (Optional)Committee Email    (optional)Street AddressCommittee Website   (optional)CityStateZip Code*(Area Code) Day Telephone*(Area Code) Evening TelephoneElection DatePrimaryMay MunicipalFire DistrictElection Type: (Select One)GeneralRun-OffSpecial
Statewide CommitteeCounty/Local CommitteeElection Related CommitteeBallot Question Committee
CountyLegal Name of Election District or MunicipalityPolitical Party, if any
CHAIRPERSONNameMailing AddressCityStateZip Code *(Area Code) Day Telephone *(Area Code) Evening TelephoneTREASURERNameMailing AddressCityStateZip Code *(Area Code) Day Telephone *(Area Code) Evening TelephoneResident AddressCityStateZip CodeDEPOSITORY INFORMATIONName of Bank or DepositoryMailing AddressCityStateZip Code (Area 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 CommissionsForm PC Revised Sep. 2020Page 1 of 4
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 *(Area Code) Day Telephone *(Area Code) Evening TelephoneNameMailing AddressCityStateZip Code *(Area Code) Day Telephone *(Area Code) Evening TelephoneNameMailing AddressCityStateZip Code *(Area Code) Day Telephone *(Area Code) Evening Telephone
General Organizational Category or Affiliation (This section includes, but is not limited to: support of or opposition to a candidate, public officeholder, or public question or support of or affiliation with a business, union, professional or trade association, ideological group, civic association, independent expenditure only committee, or other entity.)
List the names/mailing addresses of the persons or entities having control over the affairs of the political committee. (This section 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 CodeName 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.Page 2 of 4sForm PC Revised Sep. 2020New Jersey Election Law Enforcement Commission
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 CodeName 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.Page 3 of 4New Jersey Election Law Enforcement CommissionsForm PC Revised Sep. 2020
List the economic, political or other particular interests and objectives to be advanced by the political committee.
List the name and resident address of a New Jersey resident who has been designated by the committee as the agent of the political committee to receive service of legal process.   Note: if the treasurer is a New Jersey resident, he/she may be designated to accept service of legal process.NameMailing AddressCityStateZip Code
CHAIRPERSON/TREASURER CERTIFICATION FOR PUBLIC QUESTION COMMITTEES I 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 political committee, and no candidate shall be permitted to do so during the existence of the political committee.  I am aware that if any of the statements on this document are willfully false, I may be subject to punishment.PINRegistration NumberChairpersonDatePINRegistration NumberDateTreasurer
CHAIRPERSON/TREASURER CERTIFICATION FOR POLITICAL COMMITTEES Will this committee engage in only independent expenditure activity?YESNOI 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 political committee, and no candidate shall be permitted to do so during the existence of the political committee.  I am aware that if any of the statements on this document are willfully false, I may be subject to punishment.Registration NumberPINDateChairpersonPINRegistration NumberDateTreasurer*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 4 of 4sForm PC Revised Sep. 2020
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