II

I I!
i
I

FORM R-1
NEW JERSEY

REPORT OF CONTRIBUTIONS AND EXPENDITURES

REPORT (CHECK ONE)' 29 - DAY PRE-ELECTION

ELECTION LAW ENFORCEMENT COMMISSION POBox 185. Trenton. NJ 08625-0185 (609) 292-8700 or Toll Free Withm NJ 1-888-313-ELEC (3532) Web Stte http IIwww eiec state 01 us! NAME UNITED FOR LOOI

1 1 DAY PRE-ELECTION 20 - DAY POST-ELECTION

Apr 15, July 15. Oct 15,

CANDIDATE OR COMMITIEE STREET ADDRESS CITY LOOI COUNTY BERGEN POLITICAL PARTY, IF ANY NON-PARTISAN ELECnON DATE MAY 10. 2011

Jan 15.

15 ROOSEVELT AVE STATE IZIP CODE 07644 NJ ELECTION DISTRICT OR MUNICIPALITY BOROUGH OF LOOI OFFICE SOUGHT MUNICIPAL COUNCIL ELECTION TYPE D PRIMARY RUN-OFF (CHECK ONE)

AmendmentYes

U NoD

For State Use Only

ELEC RECEIVED IIIN 11 ?ntt

[i] MUNICIPAL
DSCHOOL

D GENERAL

h SPECIAL

DO NOT ATIEMPT TO COMPLETE TABLES I AND II UNTIL SUMMARY TABLES APPROPRIATE SCHEDULES HAVE BEEN COMPLETED TABLE I. RECEIPTS THIS REPORT $ 6,275.00 $ 24.300.00 $ $ $ $ 107.00 114075 0.00 31,822 75 CUMULATIVE TO DATE $ 8,875.00 $ 24,800.00 $ $ 1nOO 1.140 75

1 MONETARY CONTRIBUTIONS OF $300 OR LESS 2 MONETARY CONTRIBUTIONS IN EXCESS OF $300 AND ALL CURRENCY CONTRIBUTIONS [Schedule A] 3 IN-KIND CONTRIBUTIONS OF $300 OR LESS 4 IN-KIND CONTRIBUTIONS IN EXCESS OF $300 [Schedule B] 5 LOANS RECEIVED IN EXCESSOF $300 AND ALL CURRENCY LOANS [ScheduleC] 6 SUBTOTAL (ADD UNES 1 THRU 5)

$ 13,00000 $ 47.992.75

7 REFUND OF EXCESSIVE CONTRIBUTIONS[AdjustmentSchedule] 8 TOTAL CONTRIBUTIONS 9 ADD FUNDS TRANSFERREDFROM PRIOR CAMPAIGN 10. TOTAL RECEIPTS TABLE II. EXPENDITURES

s
-$ 31,822.75

$ $ 47,99275 $000 $ 47,99275

(+) $000 (ADO UNE 8 + UNE 9) $ 31,822 75

1 DISBURSEMENTSCAMPAIGN EXPENSES [Schedule 1 (D)] 2 DISBURSEMENTS OTHER [Schedule 2(D)] 3 DISBURSEMENTS- CONTRIBUTIONS MADE TO OTHER CANOIDATESICOMMITTEES(Schedule3(0)] 4 CONTRIBUTIONSMADE ON BEHALF OF OTHERS [pro Rata Amount Schedules 1 (0) and 2(0)] 5 IN-KIND CONTRIBUTIONSOF $300 OR LESS (TABLE I. LINE 3) 6 IN-KIND CONTRIBUTIONS IN EXCESS OF $300 (TABLE I, LINE 4) 7 SUBTOTAL 6 REFUNDED DISBURSEMENTS[Schedule F] 9 TOTAL EXPENDITURES
New Jersey ElectIon law Enforcernert Comrmson. Jaruary 200S

$ $ $ $ $ $

26,011.17

$42,06390 $ $ $

10700 1,140 75

$ $

17700 1,140 75

(ADD UNES 1 THRU 6)

$ 27.25892
(0) $

$ 43,38165
$

(LINE 7 MINUS LINE 8) $

27.258.92

43,38165
FORMR 1

- --

- -

--

-_._-----

-------

SCHEDULE A Monetary Contributions in Excess of $300 and All Currency Contributions

CONTRIBUTOR NAME LOCAL UNION #164IBEW CONTRIBUTOR ADDRESS 205 ROBIN ROAD PARAMUS.NJ ICHECK IF CURRENCY EMPLOYER ADDRESS EMPLOYER NAME
-

-- ,-

IAGGREGATE AMOUNT I UA I t:{~} $ 1_000.00 4128111

~MOUNT(S) RECEIVED THIS PERIOD

ELECTRICIAN

1.000.00

CONTRIBUTOR NAME PAUL FADER CONTRIBUTOR ADDRESS 139 SCHRAALENBURGH HAWORTH,NJ I~HECKIF CURRENCY OCCUPATION ATTORNEY RD

EMPLOYER NAME FLORIO, PERRUCCI. STEINHARDT & FADER, LLC EMPLOYER ADDRESS 216 RTE 17N STE 300 ROCHELLE PARK, NJ

o IAGGREGATE $ 500.00

AMOUNT

UAI t:(~)

AMOUNT(S) RECEIVED THIS PERIOD

$ 50000
5/3111

CONTRIBUTOR NAME MICHAEL PERRUCCI CONTRIBUTOR ADDRESS 2351 WASHINGTON LANE BETHLEHEM. PA I~HECK IF CURRENCY OCCUPATION ATTORNEY

EMPLOYER NAME FLORIO, PERRUCCI, STEINHARDT & FADER, LLC EMPLOYER ADDRESS 216 RTE 17N STE 300 ROCHELLE PARK, NJ

IAGGREGATEAMOUNT $ MIl nn

I UA 1I:.l::lJ

AMOUNT(S) RECEIVED THIS PERIOD

$
513111 EMPLOYER NAME EMPLOYER ADDRESS

50000

CONTRIBUTOR NAME APPRAISAL SYSTEMS INC CONTRIBUTOR ADDRESS 266 HARRISTOWN RD. GLEN ROCK, NJ ICHECK IF CURRENCY OCCUPATION

IAGGREGATEAMOUNT

I UA I t:l~1 ,.. "" .. , w

AMOUNT(S) RECEIVED THIS PER10D

Is. "",. ""

513/11 EMPLOYER NAME EMPLOYER ADDRESS

$ 1,00000

APPRAISAL SERVICES

CONTRIBUTOR NAME MASER CONSUL TtNG P A CONTRIBUTOR ADDRESS 331 NEWMAN SPRINGS RD STE 203 REDBANK,NJ ICHECKIF CURRENCY OCCUPATION CONSULTANTS

\AGGREGATEAMOUNT $ 5,000.00

"'-""'-, 5/3/11
TOTAL, THIS PAGE GRAND TOTAL

AMOUNT(Sl RECEIVED THIS PERIOD

$ 5,00000

(COMPLETE THIS LINE FOR EVERY PAGE USED) (COMPLETE THIS LINE FOR LAST PAGE USED)

$8,00000 $See Last Page

FORMR 1

I I
STEVEN ROGUT

SCHEDULE A Monetary Contributions in Excess of $300 and All Currency Contributions

CONTRIBUTOR NAME EMPLOYER NAME ROGUT, McCARTHY, LLC EMPLOYER ADDRESS 37 ALDEN STREET CRANFORD. NJ ICHECK IF CURRENCY ATTORNEY CONTRIBUTOR NAME MUSJAC CONSTRUCTION. CONTRIBUTOR ADDRESS 76AVENUED LODI.NJ I~HECK IF CURRENCY OCCUPATION CONSTRUCTION LLC EMPLOYER ADDRESS

II
11

CONTRIBUTOR ADDRESS 37 ALDEN STREET CRANFORD. NJ

I AGGREGATE AMOUNT $ 1..500.00

.,
513111
EMPLOYER NAME

IAMOUNT(S) RECEIVED THIS PERIOD $

1.500.00

IAGGREGATE AMOUNT $ 400.00

IUAII:\~J

____

AMOUNT(S) RECEIVED THIS PERIOD $40000

5/3111 EMPLOYER NAME EMPLOYER ADDRESS

CONTRIBUTOR NAME NEGUA ENGINEERING ASSOCIATES CONTRIBUTOR ADDRESS 34 PARK AVENUE LYNDHURST, NJ I~HECK IF CURRENCY OCCUPATION

IAGGREGATE AMOuNI

~MOUNT(S)

RECEIVED THIS PERIOD

Is 7.500.00
5/4111
EMPLOYER NAME EMPLOYER ADDRESS

$ 1,500.00

ENGINEERING FIRM

CONTRIBUTOR NAME ALAN SPINIELLO CONTRIBUTOR ADDRESS 46 ESSEXST HACKENSACK,NJ ICHECK IF CURRENCY OCCUPATIONATTORNEY

I:GGREGATE 1 S ., Ann nn

AMOUNT

,-~..-~
4128/11, 5/10111 EMPLOYER NAME

AMOUNT(S) RECEIVED THIS PERIOD

$ 2,80000

CONTRIBUTOR NAME RICHARD DIMARIA CONTRIBUTOR ADDRESS 29 LONG VALLEY ROAD LODI, NJ

DIMARIA & DIMARIA PUBLIC ACCOUNTANTS EMPLOYER ADDRESS 245UNIONST

CHECK IF CURRENCY

I nnl au
I~GGREGATEAMOUNT $ 3,000.00
KI:\,;I:IVI:U

AMOUNT{S) RECEIVED THIS PERIOD $ 2.70000

OCCUPATION - ACCOUNTANT

418111. 5/10111
TOTAL. THIS PAGE GRAND TOTAL $14.700.00 SSEE NEXT PAGE
FORMR 1

(COMPLETE THIS LINE FOR EVERY PAGE USED) (COMPLETE THIS LINE FOR LAST PAGE USED)

SCHEDULE A
Monetary Contributions in Excess of $300 and All Currency Contributions
CONTRIBUTOR NAME JGNAZIO CANGiAlOSI CONTRIBUTOR ADDRESS 417 SADDLE BACK TRAIL FRANKUN LAKES, NJ I~HECK IF CURRENCY
I

EMPLOYER NAME TAYLOR DOORS EMPLOYER ADDRESS 417 SADDLE BACK TRAIL

FRANKUN LAKES NJ ~ ....... IAGGREGATE AMOUNT I UA I t:.(lS) " ... IAMOUNT(S) RECEIVED THIS PERIOD $ 500 00

OCCUPATION

BUILDING. MFG.

5110/11
EMPLOYER NAME EMPLOYER ADDRESS

$ 500.00

CONTRIBUTOR NAME KLEIN OUTDOOR ADVERTISING CONTRIBUTOR ADDRESS 54 BROAD ST SUITE 200A REDBANK,NJ I~HECK IF CURRENCY OCCUPATION ADVERTISING

IAGGREGATEAMOUNT $ SOO.OO

UAI t:.(lS)

AMOUNT(S) RECEIVED THIS PERIOD $50000

AGENCY

5111/11
CONTRIBUTOR NAME FRIENDSOFGARYPAPARO~ CONTRIBUTOR ADDRESS 149 WESTERVELT PLACE LODI, NJ 07644 ICHECK IF CURRENCY OCCUPATION EMPLOYER NAME EMPLOYER ADDRESS

AGGREGATE AMOUNT IUAI t:(lS) $ 500.00

,-~

IAMOUNT(S) RECEIVED THIS PERIOD $ 60000

CAMPAIGN FUND

519/11
EMPLOYER NAME EMPLOYER ADDRESS

CONTRIBUTOR NAME CONTRIBUTOR ADDRESS

I~HECKIF CURRENCY OCCUPATION CONTRIBUTOR NAME CONTRIBUTOR ADDRESS

IAGGREGATEAMOUNT

,. ,

.. \"'J

, .. ..., .,. ~

AMOUNT(S) RECEIVED THIS PERIOD $

Is

EMPLOYER NAME EMPLOYER ADDRESS

'ICHECKIF CURRENCY OCCUPATION

IAGGREGATEAMOUNT

AMOUNT(S) RECEIVED THIS PERIOD

(COMPLETE THIS LINE FOR EVERY PAGE USED) (COMPLETE THIS LINE FOR LAST PAGE USED)

TOTAL. THIS PAGE GRANO TOTAL

$1.60000 $24,30000
FORMR'

In-Kind Contributions in Excess of $300

CONTRIBUTOR NAME EMPLOYER NAME

SCHEDULE B

Anthony Luna
CONTRIBUTOR ADDRESS

Borou!b of Loch
EMPLOYER ADDRESS

42 Ganbaldi

Ave

One Memorial Drive Lodi. NJ 07644

I~GGREGATEAMOUNT DATE(S) RECEIVED AMOUNT(S) RECEIVED THIS PERIOD

Loch NJ 07644 $40825

OCCUPATION

$33825 5/031l011

Borou2h Mao8eer
DESCRIPTION OF IN-KIND CONTRIBUTION(S)

Staplesl madID2 supplies and posta2e

CONTRIBUTOR NAME EMPLOYER NAME EMPLOYER ADDRESS

Vlel's Restaurant
CONTRIBUTOR ADDRESS

2 Mercer Street Lodi. NJ 07644

I AGGREGATE AMOUNT DATE(S) RECEIVED AMOUNT(S) RECEIVED THIS PERIOD

$80250
OCCUPAllON

$802.50 510412011

Business owner
DESCRIPTION OF IN-KIND CONTRIBUTION(S}

Food for c:ampaim raUv

CONTRIBUTOR NAME CONTRIBUTOR ADDRESS EMPLOYER NAME EMPLOYER ADDRESS

I~GGREGATE OCCUPAllON DESCRIPTION OF IN-KIND CONTRIBUTION(S)

AMOUNT

DATE(S) RECEIVED

AMOUNT(S) RECEIVED THIS PERIOD

CONTRIBUTOR NAME CONTRIBUTOR ADDRESS

EMPLOYER NAME EMPLOYER ADDRESS

.
I~GGREGATE OCCUPATION DESCRIPTION OF IN-KIND CONTRIBUTION(S) AMOUNT DATE(S) RECEIVED AMOUNT(S) RECEIVED THIS PERIOD

(COMPLETE THIS UNE FOR EVERY PAGE USED) (COMPLETE THIS UNE FOR LAST PAGE USeD)
New Jersey Eladlon law E~ Comm.SSIOI1 January, 2005

TOTAL. THIS PAGE GRAND TOTAL

$ 1,140.75 $ 1,140.75.
FORMR 1

SCHEDULE 11..QJ- DISBURSEMENTS

Campaign Expenses
PAYMENT CHECK NO PAYEE NAME AND ADDRESS PURPOSE FULL AMOUNT PRO-RATA AMOUNT THIS REPORTING ENTITY 5 880.00 $ PRO-RATA AMOUNT OTHERS

DATE

4130/11 4/30/11 4/30/11 4/30/11 4/30/11 S/03/11 5/03/11 5/03/11

110 111 112 113 114 115 116 117 118 119 120 121 122 123

4128/11
5/02/11 5/03/11 5/04/11 5/04/11 5/04111

LOO. POST OFFICE Washmgton Ave. Lodi, NJ VFW-LODI UDloDSt. Lodl, NJ SCARDINO'S PIZZA Soutb Main St. Loch, NJ LAURACIMA 85 Avenue D Lodi, NJ JOSPEPH LICATA 15 N Woodside Ave. Lodl, NJ tom POST OFFICE Wasbington Ave. Lodl, NJ LODI H.IGH SCHOOL Putnam Ave. Lede, NJ MARC SHRIEKS 27 Keasler Ave. Lodi, NJ PRESTO PRINT & COpy 79-3 S. Main St Lodl, NJ NANCY 0' ARRIGO 152 SchepIS Ave, Saddlebrook, NJ AMERICAN GRAPHIC SYSTEM 39-26 Rte 4 E. Fairlawn, NJ PRESTO PRINT & COpy 79-3 S. MaID St Lodi, NJ LODI POST OFFICE. Wasbington Ave. Lodi, NJ VJCl RESTAURANT

Postage for mailings Hall rental for eam palgn kick-off Pizza ror rally Lodi PostOmcel stamps Staplesl mailing matenal Mailings ror Dyers Lodi H.S. Band Wagon fund raiser Staples 1 Lod. Post Omce PrlDbDglFlyers Grapbics/design Lawn signs PrlDtlDglFlyers Postage for mailings Room rental for campaign rally Dyers

880.00

S 350.00 S 350.00

s s s
5

350.00 3~.OO 132.00 30.58

s
S

132.00 30.58

s 2,635.80 s
210.00 656.46

52,635.80 S 210.00

s
s

s
s s
s s
S

656.46

S 1,266.88 700.00 300.00

S 1,266.88 700.00 300.00 1,214.45 3,080.00 300.00

s s
S

5 1,214.45 3,080.00 300.00

2 Mercer St Lodi, NJ

$ (COMPLETE THIS LINE FOR EVERY PAGE USED) (COMPLETE THIS LINE FOR LAST PAGE USED)
New Jersey ElectIOn law Enforcement CommISSion, January, 2005

12,106.17 26,01117

12,10617

$ $

TOTAL, THIS PAGE $ GRAND TOTAL 6

FORM R1

$ 26,011.17

- ------ -------------------------------------------------------------~----

SCHEDULE 1LQl- DISBURSEMENTS Campaign Expenses

PAYMENT

DATE

CHECK NO

PAYEE NAME AND ADDRESS

PURPOSE

FULL AMOUNT

PRORATA AMOUNT THIS REPORTING ENTITY 5 88.00 107.00 170.00 $

PRO-RATA AMOUNT OTHERS

5/08/11 5/10/11 5/10/11 5/10/11 4/30/11 5/11111 5/11/11 5/11111 5111/11 5/11/11 5111/11

124 125 126 127 128 129 130 131 132 133 134

LODI POST OFFICE Washington Ave. Locli, NJ AMERICAN GRAPHIC SYSTEM 39-26 Rte 4 E. Fairlawn, NJ LODIPIZZA Rte 46 West, Lodi, NJ VFW-LODI Umon St. Lodi, NJ TJPIZZA 120 Klpp Ave. Lodi, NJ MARC SHRIEKS 27 Keasler Ave. Lodl, NJ LAURACIMA 85 Avenue D Lodl, NJ PAULA FIDUCCIA 7 Redstone lane, Lodl NJ BRUCE MASOPUST 76 Charlton Ave. Loch, NJ PATRICIA LICATA 15 N. Woodside Ave. Lodi, NJ FRANK LICATA, JR. 15 N. Woodside Ave. Lodl, NJ

Stamps Lawn signs Lun<:h for poll penonoel Hall rental for campaagn BIght Pizza for campaign night Campaign -loan repayment Campaign -loan repayment Campaign - loan repayment Campaign -loan repayment Campaign -loan repayment Sign disposal/pick up & drop off

s s s
S

88.00 107.00

s s
5

S 170.00
350.00 110.00 1,000.00

S 350.00 llO.OO 1,000.00

$3,000.00 53,000.00 $3,000.00 53,000.00 5 80.00

53,000.00 53,000.00 53,000.00 53,000.00 5 80.00

$ (COMPLETE THIS LINE FOR EVERY PAGE USED) (COMPLETE THIS LINE FOR LAST PAGE USED)
New Jersey ElectIon Law Enforcement CommiSSIOn, January, 2005

13,90500 26,011.17

13,90500

$ $

TOTAL, THIS PAGE GRAND TOTAL $ $ 26,011.17

FORMRl

SCHEDULE E
Outstanding Obligations

Creditor's Name

Address

Descnptlon

Amount

I
TOTAL $ 0.00 OUTSTANDING OBLIGATI<;)NS

SCHEDULE F
Refunded Disbursements
Amount

Date

Full Name

Address

Descnptlon

I '

SCHEDULE F TOTAL
9

000
FORMR-\

STATEMENT OF CAMPAIGN DEPOSITORY AND CAMPAIGN TREASURER

Opening Balance, thiS report (Insert Closing balance of last report, or, If thIS ISthe first report filed by thiS enbty for thIS elecbon, Insert zero) Funds Transferred from Pnor Campaign $ ---------

$
$

Deposits (Include Interest) Disbursements (Include bank charges)

Closing Balance, this Report SPENCER SAVINGS BANK NAME OF BANK OR DEPOSITORY 107 S MAIN STREET LODI, NJ 07644 JEROME J MANZETTI NAME OF TREASURER 15 ROOSEVELT AVENUE LODI, NJ 07644 ADDRESS OF TREASURER 801074113 ACCOUNT NUMBER ADDRESS OF BANK OR DEPOSITORY

$
UNITED FOR LODI NAME OF ACCOUNT

(973) 931~148

"TELEPHONE NUMBER (DAY)

CERTIFICATION
I certify that the statements on this document are true. and that the contnbubon amounts received conform wHh the Irmttabons designated by law I am aware that If any of the atatements are Willfully false. I may be subject to pUnJah 5/26/11 DATE 5/26111 LauraCima PRINT FULL NAME (CANDIDATE) Paula Frduccra

DATE
5126nl DATE

PRINT FULL NAME (CANDIDATE)

Patricia Licata PRINT FULL NAME (CANDIDATE)

DATE

PRINT FULL NAME (TREASURER)

SIGNATURE (TREASURER)

Treasurers for Gubernatorial and legISlative candidates are reqUired to receIVe training WIth the New Je. ' Elecbon Law Enforcement CommtSSlOn Check here 0 If you have complebtd the training and enter your Treasurer Traming 10#

DECLARATION OF FINAL REPORT

If this ISthe final report, SIgn applicable Declarabon below as well as Certlficabon above Chapter 65 of the Laws of 1993 requires that all filing entities c:onbnue to file reports With the COmml88ion unbl all campaign business ISwound up and the fund 18 dissolved

o I cerbfy that all contnbubons or other monies received by thiS election fund have been disbursed. that there are no outstanding
loans or other obligations. and that the election fund has wound up Its bUSiness and has been dl880lved

DATE

PRINT FULL NAME (CANDIDATE)

SIGNATURE (CANDIDATE)

DATE
DATE

PRINT FULL NAME (CANDIDATE)

SIGNATURE (CANDIDATE)

PRINT FULL NAME (CANDIDATE)

SIGNATURE (CANDIDATE)

DATE
New Jersey Eledlon ~

PRINt FuLL NAME (TREASURER)

11

SIGNATURE (TREASURER)
FORMR 1
""" mUll not be provadcd

E~ CommINIOIt. JIIflUIIIJ 2005 "Leave 1hu field bllDk If your Idophcne _bee I. unhstcd I'InuaIrt to r!..I.S.A. 47 IA I I unhltcd Ideph"" umbee u _ot. publIG _

1Ib. forro

STATEMENT OF CAMPAIGN DEPOSITORY AND CAMPAIGN TREASURER

Opening Balance, this report
(Insert closmg balance of last report, or, If thiS IS the first report filed by thiS entity for thIS election, Insert zero)

$ $

47.27 0.00

Funds Transferred

from Prior Campaign

Deposits (Include Interest) Disbursements

(Include bank charges)

$ 30,575.00 $ 26.011.17 $
801074113 ACCOUNT NUMBER ADDRESS OF BANK OR DEPOSITORY

Closing Balance, thiS Report

SPENCER SAVINGS BANK NAME OF BANK OR DEPOSITORY 107 S MAIN STREET LODI, NJ 07644 JEROME J MANZEm NAME OF TREASURER 15 ROOSEVELT AVENUE LODI, NJ 07644 ADDRESS OF TREASURER

4,611.10
UNITED FOR LODI NAME OF ACCOUNT

(973) 931-4148 *TELEPHONE NUMBER

(DAY)

CERTIFICATION
I cerbfy that the statements on thiS document are true, and that the contnbution amounts received co deSignated by law I am aware that If any of the statements are Willfully false. , may INHI b~t to msh t Marc N Schneks PRINT FUll NAME (CANDIDATE)

5/26/11
DATE

SIl6/11

Bruce Masopust PRINT FULL NAME (CANDIDATE)

DATE

PRINT FULL NAME (CANDIDATE)

5116111

Jerome J Manzetb PRINT FULL NAME (TREASURER)

DATE

Treasurers for Gubernatorial and LegISlative candidates are reqUired to receive training WIth the New Jersey Election Law Enforcement Commission Check here 0 If you have completed the tramlng and enter your Treasurer Tramlng 10#

DECLARATION OF FINAL REPORT

If thIS 18 the final report, Sign applicable Declaration below as well as Certlficabon above. Chapter 65 of the Laws of 1993 requires that all filing entitles continue to file reports WIth the CommiSSIOn until all campaign buslRess IS wound up and the fund IS diSSOlved

I certify that all contnbutlons or other mOnies receJved by thiS election fund have been diSbursed, that there are no outstanding
loans or other obligations, and that the eleebon fund has wound up Its bUSiness and has been dISSolved

DATE

PRINT FULL NAME (CANDIDATE)

SIGNATURE (CANDIDATE)

DATE

PRINT FULL NAME (CANDIDATE)

SIGNATURE (CANDIDATE)

DATE

PRINT FULL NAME (CANDIDATE)

SIGNATURE (CANDIDATE)

DATE

PRINT

FUll

NAME (TREASURER) 11

SIGNATURE (TREASURER)
FORMR 1

New Jersey Elecllon Law Enforcement ComnllSSlOl'l January 2005 \.ea ve duo field blink If your .e1ephoneDUmber ,s ""h ed Pumlantlo tI.tS.A. 47 lA I t

1IIIl1 ed

teleph ""'b .'.nol.

pubh. record d mIlS' DO'b. PTQVldedOIl duo form