LM-3 Form LM-3 Labor Organization Annual Report

Form Approved
U.S. Department of Labor
Office of Management and Budget
Employment Standards Administration
No. 1215-0188
Office of Labor-Management Standards
FOR USE BY LABOR ORGANIZATIONS WITH LESS THAN $250,000 IN TOTAL ANNUAL RECEIPTS
Expires: 11-30-2006
Washington, DC 20210
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.

FORM LM-3 LABOR ORGANIZATION ANNUAL REPORT
READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT

For Official Use Only

1. FILE NUMBER

2. PERIOD COVERED
MON
DAY

3. (a) AMENDED – If this is an amended report correcting a previously filed
report, check here:

YEAR

(b) TERMINAL – If your organization ceased to exist and this is its terminal
report, see section XII of the instructions and check here:

From

(c) SUBSIDIARY – If this is a report for a subsidiary organization of your
union as defined in section X of the instructions, check here:

Through

8. MAILING ADDRESS (Type or print in capital letters)
First Name
Last Name

4. AFFILIATION OR ORGANIZATION NAME
5. DESIGNATION (Local, Lodge, etc.)

6. DESIGNATION NUMBER
P.O. Box – Building and Room Number (if any)

7. UNIT NAME (if any)
Number and Street

9. Are your organization’s records kept at its mailing address? (If “No,” provide
address in Item 56.)
Yes

No

City
State

ZIP Code + 4

56. ADDITIONAL INFORMATION

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:

__________________________________________

58. SIGNED:

____________________________________________

(If other title, see
instructions.)
________________________ ________________________
Date
Form LM-3 (Revised 2004)

Telephone Number

(If other title, see
instructions.)
________________________ ________________________
Date

Telephone Number

FILE NUMBER:

COMPLETE ITEMS 10 THROUGH 23
10. During the reporting period did the labor organization have a ‘subsidiary
organization” as defined in section X of the instructions?
Yes

No

18. During the reporting period did the labor organization have loans
totaling more than $250 to any officer, employee, or member, or make any
loans to a business enterprise?
Yes

11. During the reporting period did the labor organization 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?
Yes

19. How many members did your organization have at the end of the
reporting period?

No

12. During the reporting period did the labor organization have a political
action committee (PAC) fund?
Yes

No

No

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?

13. During the reporting period did the labor organization acquire or dispose 21. During the reporting period did the labor organization have any changes
of any assets in any manner other than by purchase or sale?
in its constitution and bylaws, other than the rates of dues and fees, or in
Yes
No
practices/procedures listed in the instructions? (If the constitution and bylaws
14. During the reporting period did the labor organization have an audit or
review of its books and records by an outside accountant or by a parent
body auditor/representative?
Yes

No

17. During the reporting period did the labor organization pay any employee
salary, allowances, and other expenses which, together with any payments
from affiliates, totaled more than $10,000?
Yes

22. 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.)

No

16. During the reporting period did the labor organization 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?
Yes

No

No

15. During the reporting period did the labor organization discover any loss
or shortage of funds or other assets? (Answer “Yes” even if there has been
repayment or recovery.)
Yes

Yes

Rates of Dues and Fees
Dues/Fees

Amount

Unit

Minimum

Maximum

(a) Regular Dues/Fees
per

(b) Initiation Fees
per

(c) Transfer Fees
per

No

(d) Work Permits
per

If the answer to any of the above questions is “Yes”, provide details in Item 56 (Additional Information) as explained in the instructions for each Item.
Form LM-3 (Revised 2004)

24. ALL OFFICERS AND DISBURSEMENTS TO OFFICERS
(A) Name

(B) Title
1. Last Name

(List all persons who held office during the reporting period even if they
received no salary or other disbursements. Use all capital letters.)
(C) Status *
(Enter title of officer, such as PRESIDENT or TREASURER.)
First Name

Last Name

Last Name

First Name
Status

First Name

Middle Initial

Title

4.

Last Name

Status

First Name

Middle Initial

Title

5.

Last Name

Status

First Name

Middle Initial

Title

6.

Last Name

Status

First Name

Middle Initial

Title

7.

Last Name

Status

First Name

Middle Initial

Title

8.

Totals from additional pages (if any)

9.

Totals of Lines 1 through 8

Allowances and Other
Disbursements
(E)

Status

Title

3.

Gross Salary (before
taxes and other
deductions)
(D)

FILE NUMBER:

Middle Initial

Title

2.

Enter Amounts in Dollars Only – Do Not Enter Cents

Status

10. Less Deductions
The Total from Line 11 will be entered in Item 45 11. Net Disbursements
* Code for (C) Status: past officer – P; continuing officer – C; new officer during the reporting
period – N.

Form LM-3 (Revised 2004)

(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.)

Total
(F)

FILE NUMBER:

Enter Amounts in Dollars Only – Do Not Enter Cents
ASSETS

Start of Reporting Period
(A)

STATEMENT A
ASSETS AND LIABILITIES

Item

End of Reporting Period
(B)

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 LIABILITITES

Start of Reporting Period
(C)

End of Reporting Period
(D)

30. Other Assets
31. TOTAL ASSETS

37. NET ASSETS
(Item 31 less Item 36)
CASH RECEIPTS

STATEMENT B
RECEIPTS AND DISBURSEMENTS

LIABILITIES
Item

CASH DISBURSEMENTS

AMOUNT

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 or more, your organization must file
Form LM-2 instead of this form.

53. Loans Made
54. Other Disbursements
55. TOTAL DISBURSEMENTS

Form LM-3 (Revised 2004)

AMOUNT

56. ADDITIONAL INFORMATION

Form LM-3 (Revised 2004)

FILE NUMBER: