T-1 Form T-1 Trust Annual Report

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

FORM T-1 TRUST ANNUAL REPORT

Form Approved
Office of Management and Budget
No. xxxxxxxx
Expires: xx-xx-xxxx

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)

T

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. TAX STATUS OF TRUST

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:
on

PRESIDENT
/

/
Date

Form T-1 (2003)

(

)

27. SIGNED:
on

Telephone Number

TREASURER
/

/

Date

(

)
Telephone Number

Page 1 of 5

COMPLETE ITEMS 16 THROUGH 25

-

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

T

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.)
Yes
No

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

$

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?

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

$

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

$

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

$

Yes

No

18. During the reporting period did the trust liquidate, reduce or
write-off any liabilities without full payment of principal and interest?
Yes

No

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?
Yes

-

No

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?
Yes
No

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

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. ADDITIONAL INFORMATION (if more space is needed, attach additional pages properly identified.)
Item Number

Form T-1 (2003)

Page 2 of 5

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):

T

-

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))

Form T-1 (2003)

Page 3 of 5

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):

T

-

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 (2003)

Page 4 of 5

SCHEDULE 3 - DISBURSEMENTS TO OFFICERS AND EMPLOYEES OF THE TRUST

-

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

T

-

Page 1 of _____________________
Full Name

(A) LAST, FIRST, MIDDLE INITIAL

Title

Treasurer, Trustee, Attorney, etc.

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 (2003)

Page 5 of 5

CONTINUATION ITEMIZATION PAGE FOR RECEIPTS/DISBURSEMENTS SCHEDULES 1 and 2

-

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

Schedule

Page Number

T

-

Total Number of Continuation Pages

Continuation Itemization Page

Name and Address
(A)

Purpose
(C)

(B) Type or Classification

(F) Total of All Transactions Listed Above
Form T-1 (2003)

Date
(D)

Amount
(E)

SCHEDULE 3 - DISBURSEMENTS TO OFFICERS AND EMPLOYEES OF THE TRUST
Page ___________________ of _____________________
Full Name

(A) LAST, FIRST, MIDDLE INITIAL

Title

Treasurer, Trustee, Attorney, etc.

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 of Lines 1 through 9
Form T-1 (2003)

Continuation Page
Gross Salary
Disbursements (before
any deductions)
(B)

Allowances
(C)

-

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

Disbursements for Official
Business
(D)

T

Other Disbursements
(E)

TOTAL
(F)