LM-20 Agreement and Activities Report

86'HSDUWPHQWRI/DERU
2IILFHRI/DERU0DQDJHPHQW
6WDQGDUGV
:DVKLQJWRQ'&

FORM LM-20
AGREEMENT AND ACTIVITIES REPORT

)RUPDSSURYHG
2IILFHRI0DQDJHPHQW
DQG%XGJHW
1R
([SLUHV902

7KLVUHSRUWLVPDQGDWRU\XQGHU3/DVDPHQGHG)DLOXUHWRFRPSO\PD\UHVXOWLQFULPLQDOSURVHFXWLRQILQHVRUFLYLO
SHQDOWLHVDVSURYLGHGE\86&RU5HTXLUHGRISHUVRQVLQFOXGLQJlDERUrHODWLRQVcRQVXOWDQWVDQGoWKHUiQGLYLGXDOV
DQGoUJDQL]DWLRQVuQGHU6HFWLRQERIWKH/DERU0DQDJHPHQW5HSRUWLQJDQG'LVFORVXUH$FWRIDVDPHQGHG/05'$.

)RU2IILFLDO8VH2QO\

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.

E

 )LOH1XPEHU

C-

Person Filing
 1DPHDQGPDLOLQJDGGUHVVLQFOXGH=,3&RGH

 $Q\RWKHUDGGUHVVZKHUHUHFRUGVQHFHVVDU\WRYHULI\WKLVUHSRUWDUHNHSW

1DPH

1DPH

7LWOH

7LWOH

2UJDQL]DWLRQ

2UJDQL]DWLRQ

32%R[%OGJ5RRP1RLIDQ\

32%R[%OGJ5RRP1RLIDQ\

6WUHHW

6WUHHW

&LW\

&LW\
=,3&RGH

6WDWH
 'DWHILVFDO\HDUHQGV

=,3&RGH

6WDWH

 7\SHRISHUVRQ
D

,QGLYLGXDO

E

3DUWQHUVKLS

F

&RUSRUDWLRQ

G

2WKHU6SHFLI\

Nature of Agreement or Arrangement
 )XOOQDPHDQGDGGUHVVRIHPSOR\HUZLWKZKRPPDGHLQFOXGH=,3&RGH

 'DWHHQWHUHGLQWR

1DPH
 1DPHRISHUVRQVWKURXJKZKRPPDGH

2UJDQL]DWLRQ

1DPH

7UDGH1DPHLIDQ\
32%R[%OGJ5RRP1RLIDQ\

1DPH

6WUHHW

1DPH

&LW\

1DPH
=,3&RGH

6WDWH

1DPH
Signatures

(DFKRIWKHXQGHUVLJQHGGHFODUHVXQGHUSHQDOW\RISHUMXU\DQGRWKHUDSSOLFDEOHSHQDOWLHVRIODZWKDWDOORIWKHLQIRUPDWLRQVXEPLWWHGLQWKLVUHSRUWLQFOXGLQJ
WKHLQIRUPDWLRQFRQWDLQHGLQDQ\DFFRPSDQ\LQJGRFXPHQWVKDVEHHQH[DPLQHGE\WKHVLJQDWRU\DQGLVWRWKHEHVWRIWKHXQGHUVLJQHG
VNQRZOHGJHDQGEHOLHI
WUXHFRUUHFWDQGFRPSOHWH6HHSection VIIRQSHQDOWLHVLQWKHLQVWUXFWLRQV
 6LJQHG
7LWOH

3UHVLGHQW
,IRWKHUWLWOHVHH
LQVWUXFWLRQV

President

7LWOH

2Q

7UHDVXUHU
,IRWKHUWLWOHVHH
LQVWUXFWLRQV

Treasurer

2Q
'DWH

)RUP/0

 6LJQHG

7HOHSKRQH1XPEHU

'DWH

7HOHSKRQH1XPEHU

Page 1 of 2

)LOH1XPEHUC-

)LOHU

&KHFNWKHDSSURSULDWHER[WRLQGLFDWHZKHWKHUDQREMHFWRIWKHDFWLYLWLHVXQGHUWDNHQLVGLUHFWO\RULQGLUHFWO\

D

7RSHUVXDGHHPSOR\HHVWRH[HUFLVHRUQRWWRH[HUFLVHRUSHUVXDGHHPSOR\HHVDVWRWKHPDQQHURIH[HUFLVLQJWKHULJKWWRRUJDQL]HDQGEDUJDLQ
FROOHFWLYHO\WKURXJKUHSUHVHQWDWLYHVRIWKHLURZQFKRRVLQJ

E

7RVXSSO\DQHPSOR\HUZLWKLQIRUPDWLRQFRQFHUQLQJWKHDFWLYLWLHVRIHPSOR\HHVRUDODERURUJDQL]DWLRQLQFRQQHFWLRQZLWKDODERUGLVSXWHLQYROYLQJ
VXFKHPSOR\HUH[FHSWLQIRUPDWLRQIRUXVHVROHO\LQFRQMXQFWLRQZLWKDQDGPLQLVWUDWLYHRUDUELWUDOSURFHHGLQJRUDFULPLQDORUFLYLOMXGLFLDOSURFHHGLQJ

7HUPVDQGFRQGLWLRQV([SODLQLQGHWDLOVHHLQVWUXFWLRQV:ULWWHQDJUHHPHQWVPXVWEHDWWDFKHG

Specific Activities to be Performed
)RUHDFKDFWLYLW\VHSDUDWHO\OLVWLQGHWDLOWKHLQIRUPDWLRQUHTXLUHG6HHLQVWUXFWLRQV
D1DWXUHRIDFWLYLW\

E3HULRGGXULQJZKLFKSHUIRUPHG

F([WHQWSHUIRUPHG

G1DPHDQGDGGUHVVWKURXJKZKRPSHUIRUPHG

$GGLWLRQDO1DPHDQGDGGUHVVWKURXJKZKRPSHUIRUPHGLIDQ\

1DPH

1DPH

2UJDQL]DWLRQ

2UJDQL]DWLRQ

32%R[%OGJ5RRP1RLIDQ\

32%R[%OGJ5RRP1RLIDQ\

6WUHHW

6WUHHW

&LW\

&LW\

6WDWH
D,GHQWLI\VXEMHFWJURXSVRIHPSOR\HHV

)RUP/0

=,3&RGH6WDWH=,3&RGH
E,GHQWLI\VXEMHFWODERURUJDQL]DWLRQV

Page 2 of 2