LM-15 Form LM-15 Trusteeship Report

U.S. Department of Labor
Office of Labor-Management
Standards
Washington, DC 20210
For Official Use
Only

Form approved
Office of Management
and Budget
No. 1245-0003
Expires 10-31-2013

FORM LM-15
TRUSTEESHIP 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. 461.

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.

1. File Number of Labor
Organization Held in Trusteeship

2. Type of Report
Initial (complete pages 1 through 4.)

3. Date Trusteeship Established

Semiannual for period ending
(Complete pages 1 and 2 only.)
4. Labor Organization Held in Trusteeship
Affiliation or Organization Name
P.O. Box, Bldg. and Room No., if any

Designation (Local, Lodge, etc.)
Designation Number

Number and Street
Prefix

Number

Suffix

City
Unit Name (if any)

State

ZIP Code + 4

State

ZIP Code + 4

5. Labor Organization Imposing the Trusteeship
Name
File Number
P.O. Box, Building and Room Number, if any
Number and Street
City

6. List the article(s) and section(s) of the constitution which specifically authorize imposition of the trusteeship:

Add More Item 6 Information

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.)

24. Signed

President

On

Date

Treasurer

Form LM-15 (2003)

Date

On

Treasurer
(if other title,
see instructions.)

Trustee
(if other title,
see instructions.)

Trustee

Telephone Number

25. Signed

On

26. Signed

Date

Telephone Number

27. Signed

Trustee

On

Telephone Number
Print Report

Trustee
(If other title,
see instructions.)

Date

Telephone Number

Page 1 of 4

Name of Labor Organization Held In Trusteeship

File Number

7. Check the reason(s) for establishing or continuing the trusteeship:
a. To correct corruption or financial malpractice.
b. To assure the performance of collective bargaining agreements or other duties of a bargaining representative.
c. To restore democratic procedures.
d. Other.
8. Provide a detailed statement which explains each reason checked in Item 7, above.

Add More Item 8 Information

9. During the period covered by this report
a. Did a convention or other policy-determining body meet to which the trusteed labor organization sent delegates or would have sent delegates if not in
trusteeship?
Yes
No
(if the answer is "Yes," complete and file Form LM-15A.)
b. Did the labor organization imposing the trusteeship hold an election of officers?
Yes
No
(If the answer is "Yes," complete and file Form LM-15A.)
Form LM-15 (2003)

Page 2 of 4

File Number

Name of Labor Organization Held In Trusteeship

Statement of Assets and Liabilities (Complete for Initial Report Only)
Assets as of Date Trusteeship Imposed
From
Sch. #

Item

Liabilities as of Date Trusteeship Imposed

Amount

From
Sch. #

Item

10. Cash

18. Accounts Payable

11. Accounts Receivable

19. Loans Payable

12. Loans Receivable

Amount

6

20. Mortgages Payable

1

21. Other Liabilities

13. U.S. Treasury Securities

4

14. Investments

2

22. TOTAL LIABILITIES

15. Fixed Assets

5

23. NET ASSETS (Item 17 less Item 22)

16. Other Assets

3

17. TOTAL ASSETS

Schedule 1 - Loans Receivable (See Instructions for Item 12)
(A) Name of officer, employee, member, or business
enterprise

(B) Purpose of loan, security, if any, and terms for repayment

Add More Schedule 1 Items
(C) Amount

1.
2.
3.
4. Total from additional pages (if any)
5. Total of loans not listed above
6. Total of Lines 1 through 5

Schedule 2 - Investments (See Instructions for Item 14)
(A) Description

Add More Schedule 2 Items

Schedule 3 - Other Assets (See Instructions for Item 16)
(A) Description Add More Schedule 3 Items

(B) Amount

Marketable Securities:

1.

1. Total Cost

2.

2. Total Book Value

3.

3. List each marketable security that has a book value over $1,000 and
exceeds 20% of Line 2.

4.

(B) Book Value

5.

(a)

6.

(b)

7. Total from additional pages (if any)

(c) Total from additional pages (if any)

8. Total of Lines 1 through 7

Other Investments:
Schedule 4 - Other Liabilities (See Instructions for Item 21)
(A) Description Add More Schedule 4 Items

4. Total Cost
5. Total Book Value

(B) Amount

1.
2.

6. List each other investment which has a book value over $1,000 and
exceeds 20% of Line 5. Also list each subsidiary or trust which is an
investment.

3.
4.

(a)

5.

(b)

6.

(c)Total from additional pages (if any)

7. Total from additional pages (if any)

7. Total of Lines 2 and 5
Form LM-15 (2003)

0

8. Total of Lines 1 through 7

Page 3 of 4

File Number

Name of Labor Organization Held In Trusteeship

Add More Schedule 5 Items

Schedule 5 - Fixed Assets (See instructions for Item 15)
(A) Description

(B) Cost or
Other Basis

(C) Total
Depreciation
or Amount
Expensed

(D) Book
Value

(E) Fair
Market
Value

1. Land (give location)

2. Total from additional pages (if any)
3. Buildings (give location)

4. Total from additional pages (if any)
5. Automobiles and Other Vehicles
6. Office Furniture and Equipment
7. Other Fixed Assets
8. Total of Lines 1 through 7

Schedule 6 - Loans Payable (See Instructions for Item 19)
(A) Source

Add More Schedule 6 Items

(B) Amount

1.

2.

3.

4.

5. Total from additional pages (if any)
6. Total of Lines 1 through 6

Form LM-15 (2003)

Page 4 of 4