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pdfFORM LM-3 LABOR ORGANIZATION ANNUAL REPORT
FOR USE ONLY BY LABOR ORGANIZATIONS WITH LESS THAN $250,000 IN TOTAL ANNUAL RECEIPTS
Form Approved
Office of Management and Budget
No. 1245-0003
Expires 09-30-2021
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U.S. Department of Labor
Office of Labor-Management Standards
Washington, DC 20210
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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
Fro
2. PERIOD COVERED
MO
DAY
From
3. (a) AMENDED — If this is an amended report, check here:
YEAR
(b) HARDSHIP — If filing under hardship procedures, check here:
(c) TERMINAL — If this is a terminal report, check here:
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Through
8. MAILING ADDRESS (Type or print in capital letters.)
IMPORTANT
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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)
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.
If any of the label information is incorrect, complete Items 4 through 8.
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Number and Street
5. DESIGNATION (Local, Lodge, etc.)
6. DESIGNATION NUMBER
7. UNIT NAME (if any)
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4. AFFILIATION OR ORGANIZATION NAME
City
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56. ADDITIONAL INFORMATION
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9. Are your organization’s records kept at its mailing address?
(If “No,” provide address in Item 56.)
Yes
ZIP Code + 4
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State
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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.)
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57. SIGNED: __________________________________________________________ PRESIDENT
(If other title,
/
/
(
)
—
see instructions.)
Date
Telephone Number
Form LM-3 (Revised 2016)
3-1
58. SIGNED: ____________________________________________________ TREASURER
(If other title,
/
/
(
)
—
see instructions.)
Date
Telephone Number
Page 1 of 4
During the Reporting Period Did Your Organization:
19. How many members did your
organization have at the end of the
reporting period?
No
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Yes
10. Have a “subsidiary organization” as defined in
Section X of the instructions? .............................................
20. What is the maximum amount
recoverable under your organization’s
fidelity bond for a loss caused by
any officer or employee of your
$
organization?
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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? ..................
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21. During the reporting period, did your
organization have any changes in its
Yes
constitution and bylaws (other than
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.)
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14. Have an audit or review of its books and records
by an outside accountant or by a parent body
auditor/representative?.......................................................
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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.)
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Rates of Dues and Fees
17. Pay any employee salary, allowances, and other
expenses which, together with any payments
from affiliates, totaled more than $10,000? ........................
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Dues/Fees
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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.)
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YEAR
22. What is the date of your organization’s
next regular election of officers?
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 of another labor
organization or of an employee benefit plan? .....................
Form LM-3 (Revised 2016)
No
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13. Acquire or dispose of any goods or property in
any manner other than by purchase or sale? .....................
15. Discover any loss or shortage of funds or
other property? ...................................................................
(Answer “Yes” even if there has been repayment
or recovery.)
—
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FILE NUMBER:
3-2
Amount
Unit
(a) Regular Dues/Fees
$
per
(b) Initiation Fees
$
per
(c) Transfer Fees
$
per
(d) Work Permits
$
per
Page 2 of 4
Minimum
Maximum
24. ALL OFFICERS AND DISBURSEMENTS
TO OFFICERS
(B) Title
(Enter title of officer, such as PRESIDENT or TREASURER.)
Last Name
Status
(C)*
First Name
Gross Salary
(before taxes and
other deductions)
(D)
MI
1.
Status
Last Name
First Name
MI
First Name
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Status
Last Name
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Status
First Name
MI
4.
Status
Last Name
First Name
5.
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Status
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Title
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Title
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Last Name
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3.
Title
Total
(F)
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2.
Title
Allowances
and Other
Disbursements
(E)
—
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Title
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(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:
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(A) Name
Enter Amounts in Dollars Only — Do Not Enter Cents
Last Name
First Name
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6.
Title
Status
First Name
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Last Name
7.
MI
Status
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Title
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8. Totals from additional pages (if any)
9. Totals of Lines 1 through 8
10. Less Deductions
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Enter the total from Line 11 in .............................................................................................. Item 45 11. Net Disbursements
*Code for Status (C): past officer — P; continuing officer — C; new officer during the reporting period — N.
Form LM-3 (Revised 2016)
3–3
(If any officer was not elected at a regular election in accordance with
your organization’s constitution and bylaws, explain in Item 56 on page 1.)
Page 3 of 4
Start of Reporting Period End of Reporting Period
(B)
LIABILITIES
End of Reporting Period
(C)
(D)
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..
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25. Cash ..........................
30. Other Assets…………
37. NET ASSETS
(Item 31 less Item 36)…
CASH RECEIPTS
AMOUNT
CASH DISBURSEMENTS
AMOUNT
Item
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Item
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31. TOTAL ASSETS…….
38. Dues ...............................................................
45. To Officers (from Item 24) ………………….
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40. Fees, Fines, Assessments & Work Permits…
46. To Employees (less deductions) …………..
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39. Per Capita Tax ...............................................
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41. Interest & Dividends .......................................
47. Per Capita Tax ……………………………….
48. Office & Administrative Expense……………
49. Professional Fees…………………………….
43. Other Receipts ...............................................
50. Benefits………………………………………..
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42. Sale of Investments & Fixed Assets ...............
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44. TOTAL RECEIPTS .........................................
If total receipts reported in Item 44 are $250,000
or more, your organization must file Form LM-2
instead of this form.
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STATEMENT B
RECEIPTS AND DISBURSEMENTS
Start of Reporting Period
Item
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STATEMENT A
ASSETS AND LIABILITIES
(A)
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ASSETS
Item
—
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FILE NUMBER:
Enter Amounts in Dollars Only — Do Not Enter Cents
Form LM-3 (Revised 2016)
51. Contributions, Gifts & Grants………………..
52. Purchase of Investments & Fixed Assets….
53. Loans Made……………………………………
54. Other Disbursements…………………………
55. TOTAL DISBURSEMENTS………………….
3–4
Page 4 of 4
ORGANIZATION NAME:
—
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FILE NUMBER:
ENDING DATE OF PERIOD COVERED:
PAGE ____ OF ____ ADDITIONAL PAGES
(A) Name
(B) Title
(List all persons who held office during the reporting period even if
they received no salary or other disbursements. Use all capital letters.)
other deductions)
(C)
(D)
First Name
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Allowances
and Other
Disbursements
Total
(E)
(F)
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Last Name
Gross Salary
(before taxes and
Status
(Enter title of officer, such as PRESIDENT or TREASURER.)
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24. ALL OFFICERS AND DISBURSEMENTS TO OFFICERS (continued)
Status
First Name
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Status
First Name
MI
Title
Status
First Name
Title
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Last Name
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Last Name
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Title
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Last Name
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Title
Status
First Name
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Last Name
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Title
First Name
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Last Name
Status
Title
Status
First Name
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Last Name
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Title
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Last Name
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Title
Form LM-3 (Revised 2016)
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Status
First Name
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Status
Totals
3 – I24
ORGANIZATION NAME:
—
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FILE NUMBER:
ENDING DATE OF PERIOD COVERED:
PAGE ____ OF ____ ADDITIONAL PAGES
Status
other deductions)
(C)
(D)
(Enter title of officer, such as PRESIDENT or TREASURER.)
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Title
Status
First Name
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Title
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Last Name
Status
Last Name
First Name
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Status
Last Name
First Name
Title
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Title
Status
First Name
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Last Name
Title
Title
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Status
First Name
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Last Name
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Title
Last Name
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Title
Form LM-3 (Revised 2016)
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Status
First Name
-E
Last Name
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Status
First Name
Allowances
and Other
Disbursements
Total
(E)
(F)
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First Name
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Last Name
Gross Salary
(before taxes and
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(B) Title
(List all persons who held office during the reporting period even if
they received no salary or other disbursements. Use all capital letters.)
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(A) Name
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24. ALL OFFICERS AND DISBURSEMENTS TO OFFICERS (continued)
MI
Status
Totals
3 – I24
| File Type | application/pdf |
| File Title | Microsoft Word - Form LM-3_updated_3_7_16 |
| Author | anddavis |
| File Modified | 2019-06-28 |
| File Created | 2016-07-21 |