POLITICAL COMMITTEE -
FORM PC
REGISTRATION STATEMENT AND DESIGNATION OF
CAMPAIGN TREASURER AND DEPOSITORY
NEW JERSEY ELECTION LAW ENFORCEMENT COMMISSION
P.O. Box 185, Trenton, NJ 08625-0185
Phone: (609) 292-8700
Website: www.elec.nj.gov
Committee Name
Identifying Title or Acronym (Optional)
Committee Email (optional)
Street Address
Committee Website (optional)
City
State
Zip Code
*Day Telephone
*Evening Telephone
Election Date
Election Type:
(Select One)
County
Legal Name of Election District or Municipality
Political Party, if any
CHAIRPERSON
Name
Mailing Address
City
State
Zip Code
*Day Telephone
*Evening Telephone
TREASURER
Name
Mailing Address
City
State
Zip Code
*Day Telephone
*Evening Telephone
Resident Address
City
State
Zip Code
DEPOSITORY INFORMATION
Name of Bank or Depository
Mailing Address
City
State
Zip Code
Day Telephone
Account Name
Account 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 Commission
Page 1 of 4
sForm PC Revised Jan. 2023
Required;
Primary
May Municipal
Fire District
General
Run-Off
Special
Required;
Statewide Committee
County / Local Committee
Required;
Election Related Committee
Ballot Question Committee
Required;
Required;
Required;
Required;
Required; Format : Zipcode 12345 or 12345-1234
Format : Zipcode
Format : Zipcode
Format : Zipcode
Format : Zipcode
Amendment
Required;
Required;
Required;
Required;
LIST THE NAME(S), MAILING ADDRESS(ES) AND TELEPHONE NUMBER(S) OF ANY PERSON(S) AUTHORIZED TO SIGN
CHECKS OR OTHERWISE MAKE TRANSACTIONS
Name
Mailing Address
City
State
Zip Code
*Day Telephone
*Evening Telephone
Name
Mailing Address
City
State
Zip Code
*Day Telephone
*Evening Telephone
Name
Mailing Address
City
State
Zip Code
*Day Telephone
*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 Entity
Occupation
Mailing Address
Employer Name
City
Employer Mailing Address
State, Zip Code
City, State, Zip Code
Name of Person or Entity
Occupation
Mailing Address
Employer Name
City
Employer Mailing Address
State, Zip Code
City, 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 4
sForm PC Revised Jan. 2023
New Jersey Election Law Enforcement Commission
Format : Zipcode
Format : Zipcode
Format : Zipcode
Name of Person or Entity
Occupation
Mailing Address
Employer Name
City
Employer Mailing Address
State, Zip Code
City, State, Zip Code
Name of Person or Entity
Occupation
Mailing Address
Employer Name
City
Employer Mailing Address
State, Zip Code
City, State, Zip Code
Name of Person or Entity
Occupation
Mailing Address
Employer Name
City
Employer Mailing Address
State, Zip Code
City, State, Zip Code
Name of Person or Entity
Occupation
Mailing Address
Employer Name
City
Employer Mailing Address
State, Zip Code
City, State, Zip Code
Name of Person or Entity
Occupation
Mailing Address
Employer Name
City
Employer Mailing Address
State, Zip Code
City, 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 4
New Jersey Election Law Enforcement Commission
sForm PC Revised Jan. 2023
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.
Name
Mailing Address
City
State
Zip 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.
PIN
Registration Number
Chairperson
Date
PIN
Registration Number
Date
Treasurer
CHAIRPERSON/TREASURER CERTIFICATION FOR POLITICAL COMMITTEES
Will this committee engage in only independent expenditure activity?
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.
Registration Number
PIN
Date
Chairperson
PIN
Registration Number
Date
Treasurer
*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 Commission
Page 4 of 4
sForm PC Revised Jan. 2023
Required;
Yes
No
Format : Zipcode
Stamp Text
Required Field
Processing Request...