# FORM LM

- 3 LABOR ORGANIZATION ANNUAL REPORT

This report is mandatory under P.L. 86

- 257, as amended. Failure to comply may result in criminal prosecution, fines, or civil penalties as provided by 29 U.S.C. 439 or 440.

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.

For Official Use Only 1. FILE NUMBER 2. PERIOD COVERED 3. (a) AMENDED

— If this is an amended report, check here :

MO DAY YEAR

Fro From (b) H ARDSHIP

— If filing under hardship procedures

, check here :

Through ( c ) TERMINAL

— If this is a terminal report, check here :

8. MAILING ADDRESS (Type or print in capital letters.)

IMPORTANT First Name

Peel off the address label from the back of the package Last Name

.

If the label information is correct, leave Items 4 through 8 blank. P.O. Box

 Building and Room Number (if any)

If any of th e label information is incorrect, complete Items 4 through 8.

Number and Street

4. AFFILIATION OR ORGANIZATION NAME

5. DESIGNATION (Local, Lodge, etc.) 6. DESIGNATION NUMBER City

7. UNIT NAME (if any)

State ZIP Code + 4

9. Are your organization’s records kept at its mailing add ress?

(If “No,” provide address in Item 56.) Yes No

56 . ADDITIONAL INFORMATION

Item Number

Each of the undersigned, duly authorized officers of the above labor organization, declares, under penalty of perjury and other applicable penalties of law, that all of the information submitted in this report (including the information

contained in any accompanying documents) has been examined by the signatory and is, to the best of the undersigned 's knowledge and belief, true, correct, and complete. (See Section VI on penalties in the instructions.)

57 . SIGNED: ________________________________________________________

__ PRESIDENT 58 . SIGNED: ________________________________________

___ _________ TREASURER

(If other title, (If other title,

/ / ( )

— see instructions.) / / ( )

— see instructions.)

Date Telephone Number Date Telephone Number

Form LM

- 3 ( Revised XXXX ) 3

- 1 Page 1 of 4 U.S. Department of Labor

Office of Labor

- Management Standards

Washington, DC 20210 Form Approved

Office of Management and Budget

No. 1245

- 0003

Expires XX

- XX

- XXXX FOR USE ONLY BY LABOR ORGANIZATIONS WITH LESS THAN $250,000 IN TOTAL ANNUAL RECEIPTSFILE NUMBER:

—

During the Reporting Period Did Your Organization:

Yes No

10. Have a “subsidiary organization” as defined in

Section X of the instructions ?

................................ .............

11. Create or participate in the administrat ion of a

trust or other fund or organization, as defined

in the instructions, which provides benefits for

members or their beneficiaries?

................................ ..........

12. Have a political action committee (PAC) fund?

..................

13. Acquire or dispose of any goods or property in

an y manner other than by purchase or sale?

.....................

14. Have an audit or review o f its books and records

by an outside accountant or by a parent body

auditor/representative?

................................ .......................

15. Discover any loss or shortage of funds or

other property?

................................ ................................ .... (Answer “Yes” eve n if there has been repayment

or recovery.)

16. Have any officer who was paid $10,000 or more

by your organization and also received $10,000 or

m ore as an officer or employee of another labor

organization or of an employee benefit plan?

.....................

17. Pay an y employee salary, allowances, and other

expenses which, together with any payments

from affiliates

, totaled more than $10,000?

........................

18. Have loans totaling more than $250 to any officer,

employee, or member

, or make any loans to a

business enterprise ?

................................ ...........................

(If the answer to any of the above questions is “Yes,” provide details

in Item 56 on page 1 as explained in the instructions for each item.)

Form LM

- 3 ( Revised XXXX ) 3

- 2 19. How many members did your

organization have a t the end of the

reporting period?

20. What is the maximum amount

recoverable under your organization’s

fidelity bond for a loss caused by

any officer or employee o f your

organization? 

### $

21. During the reporting perio d, did your

organization have any changes in its

constitution and bylaws (other than Yes No

rates of dues and fees) or in practices/

procedures listed in the instructions?

........................ (If the constitution and bylaws have changed,

attach two new dat ed copies. If practices/

procedures have changed, see the instructions.)

MO YEAR

22. What is the date of your organization’s

next regular election of officers?

23. What are your organization’s rates of

dues and fees?

(Enter a minimum and maximum if more

than one rate applies for any line.)

Page 2 of 4 Rates of Dues and Fees

Dues/Fees Amount Unit Minimum Maximum

( a) Regular D ues/Fees $ per

(b) Initiation Fees $ per

(c) Transfer Fees $ per

(d) Work Permits $ per(List all persons who held office during the reporting period even if

they received no salary or other disbursements. Use all capital letters.) 

### 24. ALL OFFICERS AND DISBURSEMENTS

TO OFFICERS FILE NUMBER:

—

( A ) Name

Status

( B ) Title (Enter title of officer, such as PRESIDENT or TREASURER.) (C)*

Last Name First Name MI

1.

Title Status

Last Name First Name MI

2.

Title Status

Last Name First N ame MI

3.

Title Status

Last Name First Name MI

4.

Title Status

Last Name First Name MI

5.

Title Status

Last Name First Name MI

6.

Title Status

Last Name First Name MI

7.

Title Status

8. Totals from additional pages (if any) Gross Salary

(before taxes and

other deductions)

( D ) Allowances

and Other

Disbursements

(E) Total

(F)

9. Totals of Lines 1 through 8

10. Less Deductions

Enter the t otal from Line 11 in

................................ ................................ .............................. Item 45 

###  11. Net Disbursements

(If any officer was not elected at a reg ular election in accordance with *Code for Status (C): past officer

— P; continuing officer

— C; new officer during the reporting period

— N. your organization’s constitution and bylaws, explain in Item 56 on page 1. )

Form LM

- 3 ( Revise d XXXX ) 3

– 3 Page 3 of 4 Enter Amounts in Dollars Only

— Do Not Enter CentsFILE NUMBER:

—

ASSETS Start of Reporting Period End of Reporting Period LIABILITIES Start of Reporting Period End of Reporting Period

Item (A) (B) Item (C) ( D)

25. Cash

.......................... 32. Accounts Payable

.... .

26. Loans Receivable

...... 33. Loans Payable.........

27. U.S. Treas ury Securities 34. Mortgages Payable......

28. Investments............. 35. Other Liabilities........

29. Fixed Assets

............ 36. TOTAL LIABILITIES..

30. Other Assets............

37. NET ASSETS

31. TOTAL ASSETS....... (Item 31 less Item 36)

...

CASH RECEIPTS AMOUNT CASH DISBURSEMENTS AMOUNT

Item Item

38. Dues

................................ ............................... 45. To Officers (from Item 24)

......................

39. Per Capita Tax

................................ ............... 46. To Employees (less deductions)

..............

40. Fees, Fines, Assessments & Work Permits

... 47. Per Capita Tax .....................................

41. Interest & Dividends

................................ ....... 48. Office & Administrative Expense...............

42. Sale of Investments & Fixed Assets

............... 49. Professional Fees..................................

43. Other Receipts

................................ ............... 50. Benefits...............

................................

44. TOTAL RECEIPTS

................................ ......... 51. Contributions, Gifts & Grants....................

52. Purchase of Investments & Fixed Assets....



### If total receipts reported in Item 44 are $2 5 0,000 53. Loans Made..........................................



### or more, your organization must file Form LM

- 2

instead of this form. 54. Other Disbursements..............................

55. TOTAL DISBURSEMENTS......................

F orm LM

- 3 ( Revised XXXX ) 3

– 4 Page 4 of 4STATEMENT AASSETS AND LIABILITIESSTATEMENTBRECEIPTS AND DISBURSEMENTS



### Enter Amounts in Dollars Only

— Do Not Enter Cents(List all persons who held office during the reporting period even if

they received no salary or other disbursements. Use all capital letters.) FILE NUM BER:

—

PAGE ____ OF ____ ADDITIONAL PAGES 

## 24. ALL OFFICERS AND DISBURSEMENTS TO OFFICERS **(continued)**

(A) Name Gross Salary Allowances

( b efore taxes and and Other

Status other deductions) Disbursements Total

(B) Title (Enter title of officer, such as PRESIDENT or TREASURER.) (C) (D) (E) (F)

Last Name First Name MI

Title Status

Last Name First Name MI

Titl e Status

Last Name First Name MI

Title Status

Last Name First Name MI

Title Status

Last Name First Name MI

Title Status

Last Name First Name MI

Title Status

Last Name First Name MI

Title Status

Last Name First Name MI

Title Status

Totals

F orm LM

- 3 ( Revised XXXX ) 3

– I24 ORGANIZATION NAME :

ENDING DATE OF PERIOD COVERED:(List all persons who held office during the reporting period even if

they received no salary or other disbursements. Use all capital letters.) FILE NUMBER:

—

PAGE ____ OF ____ ADDITIONAL PAGES 

## 24. ALL OFFICERS AND DISBURSEMENTS TO OFFICERS **(continued)**

(A) Name Gross Salary Allowances

( before taxes and and Other

Status other deductions) Disbursements Total

(B) Title (Enter title of officer, such as PRESIDENT or TREASURER.) (C) (D) (E) (F)

Last Name First Name MI

Title Status

Last Name First Name MI

Title Status

Last Name First Name MI

Title Status

Last Name First Name MI

Title Sta tus

Last Name First Name MI

Title Status

Last Name First Name MI

Title Status

Last Name First Name MI

Title Status

Last Name First Name MI

Title Status

Totals

F orm LM

- 3 ( Revised XXXX ) 3

– I24 ORGANIZATION NAME :

ENDING DATE OF PERI OD COVERED: