FORM D-6
INDEPENDENT EXPENDITURE COMMITTEE -
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
1. CHAIRPERSON
Name
Mailing Address
City
State
Zip Code
*Day Telephone
*Evening Telephone
2. TREASURER
Name
Mailing Address
City
State
Zip Code
*Day Telephone
*Evening Telephone
Resident Address
City
State
Zip Code
3. DEPOSITORY INFORMATION
Name of Bank or Depository - 1
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
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sForm D-6 Revised Jun. 2023
Required;
Primary
May Municipal
Fire District
General (including School Board)
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;
DEPOSITORY INFORMATION - (additional)
Name of Bank or Depository -2
Mailing Address
City
State
Zip Code
Day Telephone
Account Name
Account Number
4. 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
5. 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 or other entity.)
*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.
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sForm D-6 Revised Jun. 2023
New Jersey Election Law Enforcement Commission
Format : Zipcode
Format : Zipcode
Format : Zipcode
6. List the names/mailing addresses of the persons (other than chairperson) or entities having control over the affairs
of the independent expenditure 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 independent expenditures)
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 5
New Jersey Election Law Enforcement Commission
sForm D-6 Revised Jun. 2023
7. List the names/mailing addresses of the persons or entities not already listed herein who, directly or through an agent,
participated in the initial organization of the independent expenditure committee.
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
8. List the economic, political or other particular interests and objectives to be advanced by the independent expenditure committee.
*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
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sForm D-6 Revised Jun. 2023
9. 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 independent expenditure committee, or will
any New Jersey candidate do so in the future?
10. Is the chairperson designated herein, a chairperson of a New Jersey political party committee or a New Jersey legislative
leadership comittee?
11. Will this committee engage in only independent expenditure activity?
12. What is the total amount this committee expects to expend on independent expenditures for this election?
$
13. List the name and resident address of a New Jersey resident who has been designated by the committee as the agent of the
independent expendeture 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
14. CHAIRPERSON/TREASURER CERTIFICATION
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 independent expenditure committee,
and no candidate shall be permitted to do so during the existence of the independent expendidture 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
*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
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sForm D-6 Revised Jun. 2023
Required;
YES
NO
Required;
YES
NO
Required;
YES
NO
Format : Zipcode
Stamp Text
Required Field
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