Fillable Form approved: TRUSTEESHIP REPORT Only (Complete pages 1 (Department of Labor)

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Form approved: TRUSTEESHIP REPORT Only (Complete pages 1 (Department of Labor)

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U.S. Department of Labor
Form approved
Office of Labor-Management
Office of Management
Standards
Washington, DC 20210
and Budget
No. 1245-0003
Expires 09-30-2021
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. 461.
For Official Use
Only
READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.
2. Type of Report 3. Date Trusteeship Established
1. File Number of Labor
Organization Held in Trusteeship
Initial (complete pages 1 through 4.)
Semiannual for period ending
(Complete pages 1 and 2 only.)
4. Labor Organization Held in Trusteeship
P.O. Box, Bldg. and Room No., if any
Affiliation or Organization Name
Number and Street
Designation (Local, Lodge, etc.)
City
Designation Number
State
Unit Name (if any)
ZIP Code + 4
5. Labor Organization Imposing the Trusteeship
Name
File Number
P.O. Box, Building and Room Number, if any
Number and Street
State
City
ZIP Code + 4
6. List the article(s) and section(s) of the constitution which specifically authorize imposition of the trusteeship:
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.)
26. Signed
President
24. Signed
Trustee
(if other title,
(if other title,
see instructions.)
see instructions.)
On
On
Telephone Number
27. Signed
Treasurer
Trustee
25. Signed
(if other title,
(If other title,
see instructions.)
see instructions.)
On
On
Telephone Number
Date
Form LM-15 (2003)
FORM LM-15
TRUSTEESHIP REPORT
Date
Telephone Number
Date
Telephone Number
Date
Prefix
Number
Suffix
President
Treasurer
Trustee
Trustee
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Page 1 of 4
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Name of Labor Organization Held In Trusteeship
File Number
7. Check the reason(s) for establishing or continuing the trusteeship:
a. To correct corruption or financial malpractice.
b. To assure the performance of collective bargaining agreements or other duties of a bargaining representative.
c. To restore democratic procedures.
d. Other.
8. Provide a detailed statement which explains each reason checked in Item 7, above.
9. During the period covered by this report
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 No
(if the answer is "Yes," complete and file Form LM-15A.)
b. Did the labor organization imposing the trusteeship hold an election of officers?
(If the answer is "Yes," complete and file Form LM-15A.)
Form LM-15 (2003)
Yes No
Add More Item 8 Information
Statement of Assets and Liabilities (Complete for Initial Report Only)
Assets as of Date Trusteeship Imposed
Liabilities as of Date Trusteeship Imposed
23. NET ASSETS (Item 17 less Item 22)
Schedule 1 - Loans Receivable (See Instructions for Item 12)
Schedule 2 - Investments (See Instructions for Item 14)
Schedule 3 - Other Assets (See Instructions for Item 16)
(B) Amount
(A) Description
(A) Description (B) Book Value
Marketable Securities:
3. List each marketable security that has a book value over $1,000 and
exceeds 20% of Line 2.
Other Investments:
Schedule 4 - Other Liabilities (See Instructions for Item 21)
6. List each other investment which has a book value over $1,000 and
exceeds 20% of Line 5. Also list each subsidiary or trust which is an
investment.
Form LM-15 (2003)
Name of Labor Organization Held In Trusteeship
File Number
1.
1.
Item
From
Sch. #
Amount
Item
From
Sch. #
Amount
10. Cash
18. Accounts Payable
11. Accounts Receivable
19. Loans Payable
6
12. Loans Receivable
1
20. Mortgages Payable
13. U.S. Treasury Securities
21. Other Liabilities
4
14. Investments
2
22. TOTAL LIABILITIES
15. Fixed Assets
5
16. Other Assets
3
17. TOTAL ASSETS
(A) Name of officer, employee, member, or business
enterprise
(B) Purpose of loan, security, if any, and terms for repayment
(C) Amount
1 .
2.
3.
4. Total from additional pages (if any)
5. Total of loans not listed above
6. Total of Lines 1 through 5
1. Total Cost
2.
2. Total Book Value
3.
4.
5.
(a)
6.
(b)
7. Total from additional pages (if any)
(c) Total from additional pages (if any)
8. Total of Lines 1 through 7
4. Total Cost
(A) Description
(B) Amount
5. Total Book Value
2.
3.
4.
(a)
5.
(b)
6.
(c)Total from additional pages (if any)
7. Total from additional pages (if any)
7. Total of Lines 2 and 5
8. Total of Lines 1 through 7
0
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Page 3 of 4
Schedule 5 - Fixed Assets (See instructions for Item 15)
(A) Description
(B) Cost or
(C) Total
(D) Book
(E) Fair
Depreciation
Other Basis
Value
Market
or Amount
Value
Expensed
1. Land (give location)
2. Total from additional pages (if any)
3. Buildings (give location)
Schedule 6 - Loans Payable (See Instructions for Item 19)
(A) Source
(B) Amount
1.
2.
3.
4.
Form LM-15 (2003)
Name of Labor Organization Held In Trusteeship
File Number
4. Total from additional pages (if any)
5. Automobiles and Other Vehicles
6. Office Furniture and Equipment
7. Other Fixed Assets
8. Total of Lines 1 through 7
5. Total from additional pages (if any)
6. Total of Lines 1 through 6
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Page 4 of 4
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Form approved: TRUSTEESHIP REPORT Only (Complete pages 1 (Department of Labor)

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Completed 26 January 2021

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