FORM LM-16
Form approved
U.S. Department of Labor
Office of Labor-Management
Standards
Washington, DC 20210
Office of Management
TERMINAL TRUSTEESHIP REPORT
This report is mandatory under P.L. 86-267, as amended. Failure to comply may result in criminal prosecution, fines,
and Budget
No. 1245-0003
Expires 09-30-2021
or civil penalties as provided by 29 U.S.C. 461.
READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT
1. File Number of Labor Organization Formerly Held in Trusteeship
2. Trusteeship Termination Date (mm/dd/yyyy)
3. Labor Organization Formerly Held in Trusteeship
4. File Number of Labor Organization Terminating the Trusteeship
5. Labor Organization Terminating the Trusteeship
Name
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
Form LM-16 (2003)
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
13. Signed
Trustee
11. Signed
(if other title,
(if other title,
see instructions.)
see instructions.)
On
On
Telephone Number
Date Date
Telephone Number
Treasurer
14. Signed
12. Signed
Trustee
(if other title,
(if other title,
see instructions.)
see instructions.)
On
On
Date
Telephone Number
Date
Telephone Number
Title
Title
Title
Title
Affiliation or Organization Name
Designation (Local, Lodge, etc.)
Unit Name (if any)
P.O. Box, Building and Room Number, if any
Number and Street
City
State
ZIP Code + 4
P.O. Box, Building and Room Number, if any
Number and Street
City
State
ZIP Code + 4
For Official Use Only
Designation Number (Prefix/Number/Suffix)
