FORM IND
REPORT OF INDEPENDENT EXPENDITURES
(Persons expending their own funds, not in concert
with any other person or group)
NEW JERSEY ELECTION LAW ENFORCEMENT COMMISSION
P.O. Box 185, Trenton, NJ 08625-0185
Phone: (609) 292-8700
Website: www.elec.nj.gov
Name
Street Address
City
State
Zip Code
Day Telephone
Election Type:
Election Date
(Select One)
County
Legal Name of Election District or Municipality
Political Party
If the name entered above is an individual, please provide below the individual's occupation, and the name and address of the
individual's employer.
Occupation
Employer Name
Employer Address
EXPENDITURE INFORMATION
Payment Date
Check No.
Purpose
Amount Incurred/Not Paid
Amount Disbursed
Full Name of Payee
Full Mailing Address
Payment Date
Check No.
Purpose
Amount Incurred/Not Paid
Amount Disbursed
Full Name of Payee
Full Mailing Address
Payment Date
Check No.
Purpose
Amount Incurred/Not Paid
Amount Disbursed
Full Name of Payee
Full Mailing Address
Payment Date
Check No.
Purpose
Amount Incurred/Not Paid
Amount Disbursed
Full Name of Payee
Full Mailing Address
Total for Election
Total Disbursed
Total, Incurred/Not Paid
Registration Number
PIN
Name
Date
*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 1
sForm IND Revised Oct. 2023
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General
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mm/dd/yyyy
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mm/dd/yyyy
Amendment
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ATLANTIC COUNTY
BERGEN COUNTY
BURLINGTON COUNTY
CAMDEN COUNTY
CAPE MAY COUNTY
CUMBERLAND COUNTY
ESSEX COUNTY
GLOUCESTER COUNTY
HUDSON COUNTY
HUNTERDON COUNTY
MERCER COUNTY
MIDDLESEX COUNTY
MONMOUTH COUNTY
MORRIS COUNTY
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PASSAIC COUNTY
SALEM COUNTY
SOMERSET COUNTY
SUSSEX COUNTY
UNION COUNTY
WARREN COUNTY
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