FORM A-1CANDIDATE - SWORN STATEMENT
NEW 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.state.nj.us
Amendment
Candidate NameOffice SoughtCandidate Committee NameStreet AddressCityStateZip Code*(Area Code) Day Telephone*(Area Code) Evening TelephoneElection DatePrimaryMay MunicipalFire DistrictElection Type: (Select One)GeneralRun-OffSpecialCountyLegal Name of Election District or MunicipalityPolitical Party
I, the undersigned, do hereby certify as follows:1. The total amount expended or to be expended on behalf of my candidacy by me or by any other candidate, person, or committee shall be zero, or shall not, in the aggregate, exceed $4,500 for this election.2. I am aware that in the event the total amount expended or to be expended on behalf of my candidacy by me or by any other candidate, person or committee shall, in the aggregate, exceed $4,500, I am required to file a ''Report of Contributions and Expenditures,'' Form R-1, on each subsequent reporting date.3. I am aware that if I receive a contribution in excess of $300 in the aggregate from one source in an election or a currency (cash) contribution in any amount, I am required to report the contribution to the Commission on "Supplemental Contributor Information," Form C-1, including the identity of the source and the aggregate total of contributions therefrom, and, if the contributor is an individual, his/her occupation and the name and address of his/her employer.4. I am aware that if I receive a contribution in excess of $1,400 in the aggregate from one source starting with the 13th day before the election up to, and including, the day of the election, I am required to notify the Commission in writing on the "Supplemental Contributor Information, " Form C-1, within 48 hours of receipt of the contribution and to identify the source and the aggregate amount received therefrom during the period, and, if the contributor is an individual, his/her occupation and the name and address of his/her employer.5. I am aware that if I make, incur, or authorize an expenditure of money or other thing of value in excess of $1,400 in the aggregate to support or defeat a candidate or public question, starting with the 13th day before the election up to and including the day of the election, I am required to notify the Commission in writing within 48 hours of the expenditure on the "Supplemental Expenditure Information," Form E-1.6. I am aware that I, as a candidate, am required to designate a campaign treasurer and a campaign depository and that I am required to file with the Commission a ''Certificate of Organization and Designation of Campaign Treasurer and Depository,'' Form D-1, no later than 10 days after receipt of any contribution on behalf of my candidacy or 10 days after making any expenditure on behalf of my candidacy, whichever comes first.
CANDIDATE CERTIFICATION:I certify that the statements on this document are true. I am aware that if any of the statements are willfully false, I may be subject to punishment.Registration NumberPINCandidateDate*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 1sForm A-1 Revised Jul. 2013
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