RECALL COMMITTEE - SWORN STATEMENT

Filing with ELEC

RECALL COMMITTEE - SWORN STATEMENT

NEW JERSEY ELECTION LAW ENFORCEMENT COMMISSION

P.O. Box 185, Trenton, NJ 08625-0185
Phone: (609) 292-8700
Website: www.elec.nj.gov

Form A-4

Amendment

Recall Committee Name

Street

City

State

Zip

*Phone Number

Treasurer Name

Treasurer Address

Committee Email

Committee Website

Name of Officeholder Sought to be Recalled

Election Type (select One)

County

Legal Name of Election District or Municipality

Other

Political Party, if any

Election Date

I, the undersigned, do hereby certify as follows:

TREASURER CERTIFICATION : I certify that the statements on this document are true.I am aware that if any of thestatements are willfully false, I may be subject to punishment.

Registration Number

Candidate

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.

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