LM-16 Form LM-16 Terminal 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. 1215-0188
Expires 11-30-2006

FORM LM-16
TERMINAL TRUSTEESHIP REPORT
This report is mandatory under P.L. 86-267, 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

E
1. File Number of Labor Organization Formerly Held in Trusteeship

2. Trusteeship Termination Date (mm/dd/yyyy)

3. Labor Organization Formerly Held in Trusteeship
Affiliation or Organization Name

4. File Number of Labor Organization Terminating the Trusteeship

Designation (Local, Lodge, etc.)
5. Labor Organization Terminating the Trusteeship
Designation Number (Prefix/Number/Suffix)
Name
Unit Name (if any)
P.O. Box, Building and Room Number, if any

P.O. Box, Building and Room Number, if any

Number and Street
City

Number and Street

State

City
State

ZIP Code + 4

ZIP Code + 4

6. During the period since the last Form LM-15 trusteeship report was filed:
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 (If the answer is "Yes", complete and file Form LM-15A.)
No
b. Did the labor organization imposing the trusteeship hold an election of officers?
Yes (if the answer is "Yes", complete and file Form LM-15A.)
No
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.)

11. Signed

President

Title

13. Signed

Trustee
(if other title,
see instructions.)

Trustee

Title

On

On
Date

Telephone Number

Treasurer
(if other title,
see instructions.)

12. Signed
Title

Date

Treasurer

On

Telephone Number

14. Signed
Title

Trustee
(if other title,
see instructions.)

Trustee

On
Date

Form LM-16 (2003)

Telephone Number

Date

Print Report

Telephone Number
Page 1 of 2

Name of Labor Organization Formerly Held In Trusteeship

File Number

7. How was the trusteeship terminated?

Trusteeship Termination Date

8. How were the officers of the subordinate labor organization selected?
a. Elected by the membership

a. Dissolution of subordinate labor organization
(If a. is checked, provide details in Item 10.)

b. Other (Explain in Item 10.)

b. Merger or consolidation
(If b. is checked, provide details in Item 10.)
c. Restoration of the autonomy otherwise available to the subordinate
labor organization
(if c. is checked, complete Items 8 and 9.),
9. List the names and titles of the officers of the subordinate labor organization:

10. Additional Information

Form LM-16 (2003)

Additional Officer Names & Titles

Add More Overflow Text for This Item

Page 2 of 2