T-1 Form

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

FORM T-1 TRUST ANNUAL REPORT

Form Approved
Office of Management and Budget
No. 1245-0003
Expires: 08-31-2021

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

2. PERIOD COVERED
MO
DAY

1. FILE NUMBERS
UNION a) TRUST b)

YEAR

From
Through

3. (a) AMENDED - If this is an amended report, check
here:
(b) HARDSHIP - If filing under the hardship procedures,
check here:
(c) TERMINAL - If this is a terminal report, check here:

10. NAME OF TRUST

4. NAME OF UNION
5. DESIGNATION (Local, Lodge, etc.)

6. DESIGNATION NUMBER

11. EMPLOYER IDENTIFICATION NUMBER

7. UNIT NAME OF UNION (if any)

12. PURPOSE OF TRUST

8. MAILING ADDRESS OF UNION (use capital letters)

13. MAILING ADDRESS OF TRUST (use capital letters)

First Name

Last Name

First Name

Last Name

P.O. Box - Building and Room Number (if any)

P.O. Box - Building and Room Number (if any)

Number and Street

Number and Street

City

City

State

-

Zip Code + 4

State

9. Are the union's records kept at its mailing address? (If "No," provide
address in Item 25.)
Yes

Zip Code + 4

14. Are the trust's records kept at its mailing address? (If "No," provide
address in Item 25.)
Yes

No

No

15. Will the labor organization be submitting an independent, certified audit in
place of the remainder of Form T-1?
Yes

No

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 V on penalties in the
instructions.)

26. SIGNED:

PRESIDENT
Date

Form T-1 (2020)

Telephone Number

27. SIGNED:

TREASURER
Date

Telephone Number

Page 1 of 6

UNION FILE NUMBER (a):
TRUST FILE NUMBER (b):

Complete Items 16 Through 25
16. During the reporting period did the trust discover any
loss or shortage of funds or other property? (Answer
"Yes" even if there has been repayment or recovery.)
17. During the reporting period did the trust acquire or
dispose of any goods or property in any manner other
than by purchase or sale?
18. During the reporting period did the trust liquidate,
reduce or write-off any liabilities without full payment of
principal and interest?
19. Has the trust extended any loan or credit during the
reporting period to any officer or employee of the
reporting labor organization at terms below market rates?
20. During the reporting period did the trust liquidate,
reduce or write-off any loans receivable due from officers
or employees of the reporting labor organization without
full receipt of principal and interest?

If the answer to any of the above is "Yes," provide details in Item 25
(Additional Information) as explained in the instructions for each item.

YES

21. Enter the total assets of the trust at the
end of the reporting period.

NO
YES

22. Enter the total liabilities (debts) of the trust
at the end of the reporting period.

NO
YES

23. Enter the total receipts of the trust during
the reporting period.

NO
YES

24. Enter the total disbursements of the trust
during the reporting period.

NO
YES
NO

Please be sure to:

* Enter your labor organization's 6-digit file number and the trust's 7-digit
file number in Item 1.
* Have your labor organization's president and treasurer sign the
Form T-1 in Items 26 and 27.
* Complete Schedules 1 through 3

25. (Text entered will appear on last page of form. To enter comments, press the "General Additional Information" button.)

Page 2 of 6
Form T-1 (2020)

SCHEDULE 1 - INDIVIDUALLY IDENTIFIED RECEIPTS

UNION FILE NUMBER (a):

(List all entities from whom the trust received a total of $10,000 or more during the reporting period.)

TRUST FILE NUMBER (b):

Initial Itemization Page
Name and Address
(A)

Purpose
(C)

Date
(D)

Amount
(E)

(B) Type or Classification

(F) Total of Receipts Listed Above
(G) Total of All Receipts from Continuation Pages with this Payer
(H) Total of All Itemized Receipts with this Payer (Sum of (F) and (G))
(I) Total of All Non-Itemized Receipts with this Payer
(J) Total of All Receipts with this Payer (Sum of (H) and (I))
Page 3 of 6
Form T-1 (2020)

SCHEDULE 2 - INDIVIDUALLY IDENTIFIED DISBURSEMENTS
(List all entities that received $10,000 or more in total disbursements from the trust during
the reporting period.)

UNION FILE NUMBER (a):
TRUST FILE NUMBER (b):

Initial Itemization Page
Name and Address
(A)

Purpose
(C)

Date
(D)

Amount
(E)

(B) Type or Classification

(F) Total of Disbursements Listed Above
(G) Total of All Disbursements from Continuation Pages with this Payee
(H) Total of All Itemized Disbursements to this Payee (Sum of (F) and (G))
(I) Total of All Non-Itemized Disbursements to this Payee
(J) Total of All Disbursements to this Payee (Sum of (H) and (I))
Form T-1 (2020)

Page 4 of 6

UNION FILE NUMBER (a):

SCHEDULE 3 — DISBURSEMENTS TO OFFICERS
AND EMPLOYEES OF THE TRUST
Full Name

(A) LAST, FIRST, MIDDLE INITIAL

Title

Treasurer, Trustee, Attorney, etc.

TRUST FILE NUMBER (b):

Gross Salary
Disbursements (before
any deductions)
(B)

Allowances
(C)

Disbursements for Official
Business
(D)

Other Disbursements
(E)

(F) TOTAL

1. Full Name
Title
2. Full Name
Title
3. Full Name
Title
4. Full Name
Title
5. Full Name
Title
6. Full Name
Title
7. Full Name
Title
8. Full Name
Title
9. Full Name
Title
10. Total from Continuation pages (if any)
11. Total of Lines 1 through 10
Form T-1 (2020)

Page 5 of 6

UNION FILE NUMBER (a):

25. ADDITIONAL INFORMATION

TRUST FILE NUMBER (b):

Page 6 of 6
Form T-1 (2020)