Form LM-3 Form LM-3 Labor Organization Annual Report

F

U.S. Department of Labor

Office of Labor-Management Standards

Washington, DC 20210

Form Approved

Office of Management and Budget

No. 1215-0188

Expires 9-30-2011

ORM LM-3 LABOR ORGANIZATION ANNUAL REPORT

FOR USE ONLY BY LABOR ORGANIZATIONS WITH LESS THAN $250,000 IN TOTAL ANNUAL RECEIPTS

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.

R EAD 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 correcting a previously

MO DAY YEAR filed report, check here:

From

(b) TERMINAL — If your organization ceased to exist and this is its

Through terminal report, see Section XII of the instructions and 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

and place it here.

If the label information is correct, leave Items 4 through 8 blank. P.O. Box  Building and Room Number (if any)

If any of the 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 address?

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

56. ADDITIONAL INFORMATION (If more space is needed, attach additional pages properly identified.)

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 2004) 3 - 1 Page 1 of 4

FILE NUMBER: —

During the Reporting Period Did Your Organization: Yes No

1

0. Have a “subsidiary organization” as defined in

Section X of the instructions?

11. Create or participate in the administration 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?

1

3. Acquire or dispose of any goods or property in

any manner other than by purchase or sale?

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

by an outside accountant or by a parent body

auditor/representative?

1

5. Discover any loss or shortage of funds or

other property?

(Answer “Yes” even 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

more as an officer or employee or another labor

organization or of an employee benefit plan?

17. Pay any 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 employee?

(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 2004) 3 - 2

19. How many members did your

organization have at 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 or your

organization? $

21. During the reporting period, 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 dated copies. If practices/

procedures have changed, see the instructions.)

MO YEAR

2

2. 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.)

Rates of Dues and Fees

$____________ per _________________

(Month, Year, etc.)

$____________

$____________

$____________ per _________________

(Month, Year, etc.)

(a) Regular Dues/Fees

(b) Initiation Fees

(c) Transfer Fees

(d) Work Permits

Page 2 of 4

24. ALL OFFICERS AND DISBURSEMENTS

TO OFFICERS

Enter Amounts in Dollars Only — Do Not Enter Cents

FILE NUMBER: —

(List all persons who held office during the reporting period even if

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

(A) Name

Status

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

Last Name First Name

1.

Title Status

Last Name First Name

2.

Title Status

Last Name First Name

3.

Title Status

Last Name First Name

4.

Title Status

Last Name First Name

5.

Title Status

Last Name First Name

6.

Title Status

Last Name First Name

7.

Title Status

8. Totals from additional pages (if any)

Gross Salary

(before taxes and

o ther deductions)

(D)

Allowances

and Other

Disbursements

( E)

Total

(F)

9. Totals of Lines 1 through 8

10. Less Deductions

Enter the Total from Line 11 in Item 45  11. Net Disbursements

(If any officer was not elected at a regular 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 (Revised 2004) 3 – 3 Page 3 of 4

Enter Amounts in Dollars Only — Do Not Enter Cents

FILE NUMBER: —

S TATEMENT A

A SSETS AND LIABILITIES

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

I tem (A) (B) Item (C) (D)

25. Cash 32. Accounts Payable…..

26. Loans Receivable 33. Loans Payable………

27. U.S. Treasury 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

STATEMENT B

R ECEIPTS AND DISBURSEMENTS

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 $250,000 53. Loans Made……………………………………

or more, your organization must file Form LM-2

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

55. TOTAL DISBURSEMENTS………………….

Form LM-3 (Revised 2004) 3 – 4 Page 4 of 4

ORGANIZATION NAME:

FILE NUMBER: —

ENDING DATE OF PERIOD COVERED:

PAGE ____ OF ____ ADDITIONAL PAGES

24. ALL OFFICERS AND DISBURSEMENTS TO OFFICERS (continued)

(List all persons who held office during the reporting period even if

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

(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

Title Status

Last Name

Title Status

Last Name

Title Status

Last Name

Title Status

Last Name

Title Status

Last Name

Title Status

Last Name

Title Status

Last Name

Title Status

Totals

Form LM-3 (Revised 2004) 3 – I24

ORGANIZATION NAME:

FILE NUMBER: —

ENDING DATE OF PERIOD COVERED:

PAGE ____ OF ____ ADDITIONAL PAGES

24. ALL OFFICERS AND DISBURSEMENTS TO OFFICERS (continued)

(List all persons who held office during the reporting period even if

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

(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

Title Status

Last Name

Title Status

Last Name

Title Status

Last Name

Title Status

Last Name

Title Status

Last Name

Title Status

Last Name

Title Status

Last Name

Title Status

Totals

Form LM-3 (Revised 2004) 3 – I24