LM-15A Form LM-15A Report on Selection of Delegates and Officer

U.S. Department of Labor
Office of Labor-Management
Standards
Washington, DC 20210

FORM LM-15A
REPORT ON SELECTION OF
DELEGATES AND OFFICERS

For Official Use Only

Form approved
Office of Management
and Budget
No. 1215-0188
Expires 09-30-2011

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. 461.
TO ACCOMPANY TRUSTEESHIP REPORT, FORM LM-15, OR TERMINAL TRUSTEESHIP REPORT, FORM LM-16

E

READ THE INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS REPORT

1. File Number of Labor Organization Held in Trusteeship

3. Labor Organization Held in Trusteeship
Affiliation or Organization Name

Month/Day/Year
( mm/dd/yyyy )

Month/Day/Year
( mm/dd/yyyy )

2. Period Covered
By This Report
From:

Through:

P.O. Box, Building and Room Number, if any

Designation (Local, Lodge, etc.)

Number and Street

Designation Number (Prefix/Number/Suffix)

City

Unit Name (if any)

State

ZIP Code + 4

Part A - Selection of Delegates Complete Part A if during the reporting period a convention or other policy-determining body met to which the trusteed labor
organization sent delegates or would have sent delegates if not in trusteeship. (If the answer to any of the questions in Part A is "No", provide details in Item 20.)
8. How were the delegates nominated?
a. At a membership meeting

4. Describe the convention or other policy determining body:
a. Name of body

b. By written nomination
c. By petition
d. Other

b. Location(s)
c. Type of body

9. Was every "member in good standing" eligible to be a
candidate (subject to reasonable qualifications uniformly
imposed)?
Yes
No

d. Date(s) of meetings
Yes

5. Was the trusteed organization represented?

No

10. How was the membership notified of the date, time and,
place of the election?
a. Mail notice

6. Did the delegates from the trusteed organization participate in the business of the convention
or other policy-determining body in the same manner as other delegates?
Yes
No
7. How were the delegates from the trusteed organization selected?

b. Posting at work site
c. Union newspaper
d. Other

a. Appointed by trustee
b. Elected by the membership
c. Other

11. Was every "member in good standing" eligible to vote (subject
to reasonable qualifications uniformly
No
Yes
imposed)?

Complete Items 8 through 12 only if Item 7.c is checked.

12. Was the election held by "secret ballot"?

Yes

No

Signatures
Each of the undersigned, duly authorized officials of the labor organization imposing the trusteeship over 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 the section
on penalties in the instructions.)
President
(if other title,
see instructions.)

21. Signed

President

Title

23. Signed

Trustee
(if other title,
see instructions.)

Trustee

Title

On

On
Date

Telephone Number

Treasurer
(if other title,
see instructions.)

22. Signed
Title

Date

Treasurer

On

Telephone Number

24. Signed

Trustee
(if other title,
see instructions.)

Title Trustee

On
Date

Telephone Number

Date

Form LM-15A (2003)

Telephone Number

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Print Report

Name of Labor Organization Held In Trusteeship

File Number

Ending Date of the Period Covered

Part B - Election of Officers. Complete Part B If during the reporting period the labor organization imposing the trusteeship held an election of officers. (If the
answer to any of the questions in Part B is "No", Provide details in Item 20.)
13. What was the date of the election? (mm/dd/yyyy)

15. Did the trusteed organization participate in the election?

Yes

No

14. List the title of each officer elected:
16. How were the officers elected?
a. At a convention reported in Item 4
b. By referendum
c. Other

Complete Items 17 through 19 only if Item 16.b. is checked.
17. Was an election notice mailed to members at their last known home
address at least 15 days prior to the date of the election?

Yes

No

18. Was every "member in good standing" eligible to vote (subject to
reasonable qualifications uniformly imposed)?

Additional Officer Titles

19. Was the election held by "secret ballot'?

Yes

No

Yes

No

20. Additional Information

Form LM-15A (2003)

Add More Overflow Text for This Item

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