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) Website: www.elec.nj.govCommittee NameIdentifying Title or Acronym (Optional)Committee Email (optional)Street AddressCommittee Website (optional)CityStateZip Code*Day Telephone*Evening TelephoneElection DateElection Type: (Select One)CountyLegal Name of Election District or MunicipalityPolitical Party, if anyCHAIRPERSONNameMailing AddressCityStateZip Code*Day Telephone*Evening TelephoneTREASURERNameMailing AddressCityStateZip Code*Day Telephone*Evening TelephoneResident AddressCityStateZip CodeDEPOSITORY INFORMATIONName of Bank or DepositoryMailing AddressCityStateZip CodeDay 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 4sForm PC Revised Jun. 2021




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 TelephoneGeneral 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 Jun. 2021New 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 Jun. 2021
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 CodeCHAIRPERSON/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 NumberDateTreasurerCHAIRPERSON/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 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 Jun. 2021
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