U.S. Department of Labor
Office of Labor-Management Standards
Washington, DC 20210
FORM LM-2 LABOR ORGANIZATION ANNUAL REPORT Form Approved
Office of Management and Budget
No. 1245-0003
Expires: 08-31-2016
MUST BE USED BY LABOR ORGANIZATIONS WITH $250,000 OR MORE IN TOTAL ANNUAL RECEIPTS AND LABOR ORGANIZATIONS IN TRUSTEESHIP

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
1. FILE NUMBER
039-703
2. PERIOD COVERED
From01/01/2015
Through12/31/2015
3. (a) AMENDED - Is this an amended report:
No
(b) HARDSHIP - Filed under the hardship procedures:
No
(c) TERMINAL - This is a terminal report:No
4. AFFILIATION OR ORGANIZATION NAME
AUTO WORKERS AFL-CIO
5. DESIGNATION (Local, Lodge, etc.)
LOCAL UNION
6. DESIGNATION NBR
362
7. UNIT NAME (if any)

8. MAILING ADDRESS (Type or print in capital letters)
First Name
Timothy
Last Name
Adcock
P.O Box - Building and Room Number

Number and Street
4427 E. WILDER RD.
City
BAY CITY
State
MI
ZIP Code + 4
48706


9. Are your organization's records kept at its mailing address?


Yes

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 information contained in any accompanying documents) has been examined by the signatory and is, to the best of the undersigned individual's knowledge and belief, true, correct and complete (See Section V on penalties in the instructions.)
70. SIGNED:Pedro SantosPRESIDENT71. SIGNED:Timothy AdcockTREASURER
Date:Mar 15, 2016Telephone Number:989-684-1435Date:Mar 15, 2016Telephone Number:989-684-1435
Form LM-2 (Revised 2010)
ITEMS 10 THROUGH 21 FILE NUMBER: 039-703
10. During the reporting period did the labor organization create or participate in the administration of a trust or a fund or organization, as defined in the instructions, which provides benefits for members or beneficiaries?Yes
11(a). During the reporting period did the labor organization have a political action committee (PAC) fund?No
11(b). During the reporting period did the labor organization have a subsidiary organization as defined in Section X of these Instructions?Yes
12. 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?No
13. 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.)No
14. What is the maximum amount recoverable under the labor organization's fidelity bond for a loss caused by any officer, employee or agent of the labor organization who handled union funds?$100,000
15. During the reporting period did the labor organization acquire or dispose of any assets in a manner other than purchase or sale?Yes
16. Were any of the labor organization's assets pledged as security or encumbered in any way at the end of the reporting period?No
17. Did the labor organization have any contingent liabilities at the end of the reporting period?No
18. During the reporting period did the labor organization have any changes in its constitution or bylaws, other than rates of dues and fees, or in practices/procedures listed in the instructions?No
19. What is the date of the labor organization's next regular election of officers?05/2017
20. How many members did the labor organization have at the end of the reporting period?362
21. What are the labor organization's rates of dues and fees?
Rates of Dues and Fees
Dues/FeesAmount UnitMinimumMaximum
(a) Regular Dues/Fees2.5 hrs of str. time or 1.9 hours for public secpermonth0145
(b) Working Dues/Fees0per
(c) Initiation Fees20perone time
(d) Transfer Fees0per
(e) Work Permits0per

Form LM-2 (Revised 2010)
STATEMENT A - ASSETS AND LIABILITIES FILE NUMBER: 039-703

ASSETS
ASSETS Schedule
Number
Start of Reporting Period
(A)
End of Reporting Period
(B)
22. Cash $104,148$137,459
23. Accounts Receivable1$0
24. Loans Receivable2$0
25. U.S. Treasury Securities $0$0
26. Investments5$0
27. Fixed Assets6$288,429$288,809
28. Other Assets7$0
29. TOTAL ASSETS $392,577$426,268

LIABILITIES
LIABILITIES Schedule
Number
Start of Reporting Period
(A)
End of Reporting Period
(B)
30. Accounts Payable8$18,062$38,432
31. Loans Payable9$0
32. Mortgages Payable $0$0
33. Other Liabilities10$1,488$2,359
34. TOTAL LIABILITIES $19,550$40,791
35. NET ASSETS$373,027$385,477
Form LM-2 (Revised 2010)
STATEMENT B - RECEIPTS AND DISBURSEMENTS FILE NUMBER: 039-703

CASH RECEIPTSSCHAMOUNT
36. Dues and Agency Fees $382,905
37. Per Capita Tax $0
38. Fees, Fines, Assessments, Work Permits $230
39. Sale of Supplies $1,003
40. Interest $7
41. Dividends $42
42. Rents $10,665
43. Sale of Investments and Fixed Assets3$45
44. Loans Obtained9$0
45. Repayments of Loans Made2$0
46. On Behalf of Affiliates for Transmittal to Them $0
47. From Members for Disbursement on Their Behalf $0
48. Other Receipts14$31,595
49. TOTAL RECEIPTS $426,492
CASH DISBURSEMENTSSCHAMOUNT
50. Representational Activities15$11,139
51. Political Activities and Lobbying16$0
52. Contributions, Gifts, and Grants17$981
53. General Overhead18$5,420
54. Union Administration19$118,867
55. Benefits20$24,596
56. Per Capita Tax $208,674
57. Strike Benefits $0
58. Fees, Fines, Assessments, etc. $150
59. Supplies for Resale $1,153
60. Purchase of Investments and Fixed Assets4$8,527
61. Loans Made2$0
62. Repayment of Loans Obtained9$0
63. To Affiliates of Funds Collected on Their Behalf $0
64. On Behalf of Individual Members $0
65. Direct Taxes $12,360
  
66. Subtotal $391,867
67. Withholding Taxes and Payroll Deductions  
  67a. Total Withheld$11,391  
  67b. Less Total Disbursed$12,705  
  67c. Total Withheld But Not Disbursed -$1,314
68. TOTAL DISBURSEMENTS $393,181
Form LM-2 (Revised 2010)
SCHEDULE 1 - ACCOUNTS RECEIVABLE AGING SCHEDULE FILE NUMBER: 039-703

Entity or Individual Name
(A)
Total Account Receivable
(B)
90-180 Days
Past Due
(C)
180+ Days
Past Due
(D)
Liquidated Account
Receivable
(E)
Total of all itemized accounts receivable$0$0$0$0
Totals from all other accounts receivable    
Totals (Total of Column (B) will be automatically entered in Item 23, Column(B)) $0$0$0$0
Form LM-2 (Revised 2010)
SCHEDULE 2 - LOANS RECEIVABLE FILE NUMBER: 039-703

List below loans to officers, employees, or members which at any time during the reporting period exceeded $250 and list all loans to business enterprises regardless of amount.
(A)
Loans
Outstanding at
Start of Period
(B)
Loans Made
During Period
(C)
Repayments Received During Period
Cash
(D)(1)
Other Than Cash
(D)(2)
Loans
Outstanding at
End of Period
(E)
Total of loans not listed above     
Total of all lines above$0$0$0$0$0
Totals will be automatically entered in... Item 24
Column (A)
Item 61Item 45 Item 69
with Explanation
Item 24
Column (B)
Form LM-2 (Revised 2010)
SCHEDULE 3 - SALE OF INVESTMENTS AND FIXED ASSETS FILE NUMBER: 039-703

Description (if land or buildings give location)
(A)
Cost
(B)
Book Value
(C)
Gross Sales Price
(D)
Amount Received
(E)
Total of all lines above$45$45$45$45
computer$45$45$45$45
Less Reinvestments$0
(The total from Net Sales Line will be automatically entered in Item 43)Net Sales$45
Form LM-2 (Revised 2010)
SCHEDULE 4 - PURCHASE OF INVESTMENTS AND FIXED ASSETS FILE NUMBER: 039-703

Description (if land or buildings, give location)
(A)
Cost
(B)
Book Value
(C)
Cash Paid
(D)
Total of all lines above$8,527$8,527$8,527
construction and improvements interior paint$8,147$8,147$8,147
Furniture & Equipment purchase Laptop computer$380$380$380
 Less Reinvestments$0
(The total from Net Purchases Line will be automatically entered in Item 60.)Net Purchases$8,527
Form LM-2 (Revised 2010)
SCHEDULE 5 - INVESTMENTS FILE NUMBER: 039-703

Description
(A)
Amount
(B)
Marketable Securities 
A. Total Cost
B. Total Book Value
C. List each marketable security which has a book value over $5,000 and exceeds 5% of Line B.  
Other Investments 
D. Total Cost
E. Total Book Value
F. List each other investment which has a book value over $5,000 and exceeds 5% of Line E.  Also, list each subsidiary for which separate reports are attached.  
G. Total of Lines B and E (Total will be automatically entered in Item 26, Column(B)) $0
Form LM-2 (Revised 2010)
SCHEDULE 6 - FIXED ASSETS FILE NUMBER: 039-703

Description
(A)
Cost or Other Basis
(B)
Total Depreciation or
Amount Expensed
(C)
Book Value
(D)
Value
(E)
A. Land (give location)    
Land  1 :      Land 4427 e wilder rd bay city mi 48706$6,770 $6,770$6,770
B. Buildings (give location)    
Building  1 :      4427 e wilder rd bay city mi 48708$223,598$223,598$223,598
C. Automobiles and Other Vehicles
D. Office Furniture and Equipment$58,441$58,441$58,441
E. Other Fixed Assets
F. Totals of Lines A through E (Column(D) Total will be automatically entered in Item 27, Column(B)) $288,809$0$288,809$288,809
Form LM-2 (Revised 2010)
SCHEDULE 7 - OTHER ASSETS FILE NUMBER: 039-703

Description
(A)
Book Value
(B)
Total (Total will be automatically entered in Item 28, Column(B)) $0
Form LM-2 (Revised 2010)
SCHEDULE 8 - ACCOUNTS PAYABLE AGING SCHEDULE FILE NUMBER: 039-703

Entity or Individual Name
(A)
Total Account
Payable
(B)
90-180 Days
Past Due
(C)
180+ Days Past
Due
(D)
Liquidated Account
Payable
(E)
Total for all itemized accounts payable$0$0$0$0
Total from all other accounts payable$38,432$0$0$0
Totals (Total for Column(B) will be automatically entered in Item 30, Column(D)) $38,432$0$0$0
Form LM-2 (Revised 2010)
SCHEDULE 9 - LOANS PAYABLE FILE NUMBER: 039-703

Source of Loans Payable at Any
Time During the Reporting Period
(A)
Loans Owed at
Start of Period
(B)
Loans Obtained
During Period
(C)
Repayment
During Period
Cash
(D)(1)
Repayment
During Period
Other Than Cash
(D)(2)
Loans Owed at
End of Period
(E)
Total Loans Payable$0$0$0$0$0
Totals will be automatically entered in... Item 31
Column (C)
Item 44Item 62 Item 69
with Explanation
Item 31
Column (D)
Form LM-2 (Revised 2010)
SCHEDULE 10 - OTHER LIABILITIES FILE NUMBER: 039-703

Description
(A)
Amount at End of Period
(B)
Total Other Liabilities (Total will be automatically entered in Item 33, Column(D)) $2,359
federal payroll$995
state income tax$1,052
fed unemployment$98
MI unemployment$214
Form LM-2 (Revised 2010)
SCHEDULE 11 - ALL OFFICERS AND DISBURSEMENTS TO OFFICERS FILE NUMBER: 039-703

(A)
Name
(B)
Title
(C)
Status
(D)
Gross Salary
Disbursements
(before any
deductions)
(E)
Allowances
Disbursed
(F)
Disbursements for Official Business
(G)
Other
Disbursements not reported in
(D) through (F)
(H)
TOTAL
A
B
C
Adcock ,  Timothy  
TRUSTEE
C
$2,901$0$166$0$3,067
I
Schedule 15
Representational Activities
0 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
100 %
A
B
C
Allen ,  Patrick   H
Sgt At Arms
C
$0$0$0$0$0
I
Schedule 15
Representational Activities
100 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
0 %
A
B
C
Garcia ,  Lucia  
Chair Person UNIT 4
C
$0$0$0$0$0
I
Schedule 15
Representational Activities
100 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
0 %
A
B
C
Goulet ,  Donald   G
Retired E Board Mem
C
$0$0$0$0$0
I
Schedule 15
Representational Activities
100 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
0 %
A
B
C
Henson ,  Scott   A
Unit 2 Chairman
C
$0$0$0$0$0
I
Schedule 15
Representational Activities
100 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
0 %
A
B
C
Laczko ,  Michael  
FINANCIAL SECRETARY
C
$6,922$10,219$3,038$0$20,179
I
Schedule 15
Representational Activities
3 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
97 %
A
B
C
MORAND ,  PATRICK   D
TRUSTEE
C
$690$0$0$0$690
I
Schedule 15
Representational Activities
0 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
100 %
A
B
C
McDaniel ,  Todd  
Shop Chairman
C
$2,594$0$2,254$0$4,848
I
Schedule 15
Representational Activities
53 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
47 %
A
B
C
Mead ,  Kimberl   A
GUIDE
C
$552$0$0$0$552
I
Schedule 15
Representational Activities
0 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
100 %
A
B
C
PLUMLEY ,  JENNIFE   M
BARGAINING
N
$1,636$0$0$0$1,636
I
Schedule 15
Representational Activities
100 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
0 %
A
B
C
Pruitt ,  Shawn  
RECORDING SECRETARY
C
$2,966$0$1,655$0$4,621
I
Schedule 15
Representational Activities
0 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
100 %
A
B
C
Santos ,  Pedro   R
PRESIDENT
C
$2,651$0$3,906$0$6,557
I
Schedule 15
Representational Activities
34 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
66 %
A
B
C
Sherry ,  Stuart   B
Trustee
C
$1,571$0$0$0$1,571
I
Schedule 15
Representational Activities
0 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
100 %
A
B
C
VanBocxlaer ,  Jason  
VICE PRESIDENT
C
$259$0$178$0$437
I
Schedule 15
Representational Activities
0 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
100 %
A
B
C
White ,  Stephen   J
UNIT 3 CHAIRPERSON
C
$2,944$0$1,291$0$4,235
I
Schedule 15
Representational Activities
0 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
100 %
A
B
C
ZIELINSKI ,  JOSEPH  
CHAIR
C
$0$0$0$0$0
I
Schedule 15
Representational Activities
100 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
0 %
Total Officer Disbursements$25,686$10,219$12,488$0$48,393
Less Deductions    $8,334
Net Disbursements    $40,059
Form LM-2 (Revised 2010)
SCHEDULE 12 - DISBURSEMENTS TO EMPLOYEES FILE NUMBER: 039-703

(A)
Name
(B)
Title
(C)
Other Payer
(D)
Gross Salary
Disbursements
(before any
deductions)
(E)
Allowances Disbursed
(F)
Disbursements for Official Business
(G)
Other Disbursements not reported in
(D) through (F)
(H)
TOTAL
TOTALS RECEIVED BY EMPLOYEES MAKING $10,000 OR LESS$14,106$0$5,751$0$19,857
I Schedule 15
Representational Activities
0 % Schedule 16
Political Activities and Lobbying
0 % Schedule 17
Contributions
0 % Schedule 18
General Overhead
0 % Schedule 19
Administration
100 %
Total Employee Disbursements$14,106$0$5,751$0$19,857
Less Deductions    $3,057
Net Disbursements    $16,800
Form LM-2 (Revised 2010)
SCHEDULE 13 - MEMBERSHIP STATUS FILE NUMBER: 039-703

Category of Membership
(A)
Number
(B)
Voting Eligibility
(C)
Members (Total of all lines above) 362 
Agency Fee Payers*
Total Members/Fee Payers362 
*Agency Fee Payers are not considered members of the labor organization.
Regular members362Yes
Form LM-2 (Revised 2010)
DETAILED SUMMARY PAGE - SCHEDULES 14 THROUGH 19 FILE NUMBER: 039-703

SCHEDULE 14   OTHER RECEIPTS
1. Named Payer Itemized Receipts$6,651
2. Named Payer Non-itemized Receipts$15,731
3. All Other Receipts$9,213
4. Total Receipts$31,595
     
     
SCHEDULE 17   CONTRIBUTIONS, GIFTS & GRANTS
1. Named Payee Itemized Disbursements$0
2. Named Payee Non-itemized Disbursements$0
3. To Officers$0
4. To Employees$0
5. All Other Disbursements$981
6. Total Disbursements$981
SCHEDULE 15   REPRESENTATIONAL ACTIVITIES
1. Named Payee Itemized Disbursements$0
2. Named Payee Non-itemized Disbursements$0
3. To Officers$7,039
4. To Employees$0
5. All Other Disbursements$4,100
6. Total Disbursements$11,139
SCHEDULE 18   GENERAL OVERHEAD
1. Named Payee Itemized Disbursements$0
2. Named Payee Non-itemized Disbursements$0
3. To Officers$0
4. To Employees$0
5. All Other Disbursements$5,420
6. Total Disbursements$5,420
SCHEDULE 16   POLITICAL ACTIVITIES AND LOBBYING
1. Named Payee Itemized Disbursements$0
2. Named Payee Non-itemized Disbursements$0
3. To Officers$0
4. To Employees$0
5. All Other Disbursements$0
6. Total Disbursement$0
SCHEDULE 19   UNION ADMINISTRATION
1. Named Payee Itemized Disbursements$0
2. Named Payee Non-itemized Disbursements$19,288
3. To Officers$41,354
4. To Employees$19,857
5. All Other Disbursements$38,368
6. Total Disbursements$118,867
Form LM-2 (Revised 2010)
SCHEDULE 14 - OTHER RECEIPTS FILE NUMBER: 039-703

Name and Address
(A)
International Union UAW
8000 E. Jefferson Avenue

Detroit
MI
48214-0000
Type or Classification
(B)
Labor Union
Purpose
(C)
Date
(D)
Amount
(E)
Total Itemized Transactions with this Payee/Payer$6,651
Total Non-Itemized Transactions with this Payee/Payer$5,071
Total of All Transactions with this Payee/Payer for This Schedule$11,722
13th rebate check05/01/2015$6,651
Name and Address
(A)
Local 362 Chapter Retirees
4427 E. Wilder Rd.

Bay City
MI
48706-0000
Type or Classification
(B)
Retiree Chapter
Purpose
(C)
Date
(D)
Amount
(E)
Total Itemized Transactions with this Payee/Payer$0
Total Non-Itemized Transactions with this Payee/Payer$10,660
Total of All Transactions with this Payee/Payer for This Schedule$10,660
Form LM-2 (Revised 2010)
SCHEDULE 15 - REPRESENTATIONAL ACTIVITIES FILE NUMBER: 039-703

Name and Address
(A)




-1
Type or Classification
(B)
Purpose
(C)
Date
(D)
Amount
(E)
Total Itemized Transactions with this Payee/Payer 
Total Non-Itemized Transactions with this Payee/Payer 
Total of All Transactions with this Payee/Payer for This Schedule$0
Form LM-2 (Revised 2010)
SCHEDULE 16 - POLITICAL ACTIVITIES AND LOBBYING FILE NUMBER 039-703

Name and Address
(A)




-1
Type or Classification
(B)
Purpose
(C)
Date
(D)
Amount
(E)
Total Itemized Transactions with this Payee/Payer 
Total Non-Itemized Transactions with this Payee/Payer 
Total of All Transactions with this Payee/Payer for This Schedule$0
Form LM-2 (Revised 2010)
SCHEDULE 17 - CONTRIBUTIONS, GIFTS & GRANTS FILE NUMBER: 039-703

Name and Address
(A)




-1
Type or Classification
(B)
Purpose
(C)
Date
(D)
Amount
(E)
Total Itemized Transactions with this Payee/Payer 
Total Non-Itemized Transactions with this Payee/Payer 
Total of All Transactions with this Payee/Payer for This Schedule$0
Form LM-2 (Revised 2010)
SCHEDULE 18 - GENERAL OVERHEAD FILE NUMBER: 039-703

Name and Address
(A)




-1
Type or Classification
(B)
Purpose
(C)
Date
(D)
Amount
(E)
Total Itemized Transactions with this Payee/Payer 
Total Non-Itemized Transactions with this Payee/Payer 
Total of All Transactions with this Payee/Payer for This Schedule$0
Form LM-2 (Revised 2010)
SCHEDULE 19 - UNION ADMINISTRATION FILE NUMBER: 039-703

Name and Address
(A)
Krzysiak's House Inc.
1605 Michigan

Bay City
MI
48708-0000
Type or Classification
(B)
Caterer
Purpose
(C)
Date
(D)
Amount
(E)
Total Itemized Transactions with this Payee/Payer 
Total Non-Itemized Transactions with this Payee/Payer$19,288
Total of All Transactions with this Payee/Payer for This Schedule$19,288
Form LM-2 (Revised 2010)
SCHEDULE 20 - BENEFITS FILE NUMBER: 039-703

Description
(A)
To Whom Paid
(B)
Amount
(C)
Total of all lines above (Total will be automatically entered in Item 55.)$24,596
Dental/Hearing/Medical/Vision InsuranceDelta Dental Plan of Michigan$2,879
Dental/Hearing/Medical/Vision InsuranceSterling Insurance Group$9,522
Workers Compension InsuranceNORTH POINTE INSURANCE COMPANY$811
Pension AllocationsNational Integrated Group Pension Plan$11,384
Form LM-2 (Revised 2010)
69. ADDITIONAL INFORMATION SUMMARY FILE NUMBER: 039-703


Question 10: : operations of the building corporation are handled thru the books and records of the local union and are therefore included in the report

Question 11(b):

Question 11(b): : : : operation of the building corporation are handled though the books and records of the local union and are therefore included in this report

Question 15: These assets include tshirts bibles $45 bibles and $1153 tshirts

Schedule 13, Row1:

Schedule 13, Row1:regular members

Schedule 13, Row1:

Schedule 13, Row1:
Form LM-2 (Revised 2010)