FORM INDREPORT OF INDEPENDENT EXPENDITURES
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
NameStreet AddressCityStateZip Code*(Area Code) Day TelephonePrimaryMay MunicipalFire DistrictElection DateElection Type: (Select One)GeneralRun-OffSpecialCountyLegal Name of Election District or MunicipalityPolitical 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.OccupationEmployer NameEmployer Address
EXPENDITURE INFORMATIONPayment DateCheck No.PurposeAmount Incurred/Not PaidAmount DisbursedFull Name of PayeeFull Mailing Address
Payment DateCheck No.PurposeAmount Incurred/Not PaidAmount DisbursedFull Name of PayeeFull Mailing Address
Payment DateCheck No.PurposeAmount Incurred/Not PaidAmount DisbursedFull Name of PayeeFull Mailing Address
Payment DateCheck No.PurposeAmount Incurred/Not PaidAmount DisbursedFull Name of PayeeFull Mailing Address
Grand Total
Registration NumberPINDateName*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 IND Revised Jul. 2013
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