DOL Form Report (Disclosure)

9/12/13 10:34 AM

Return FORM LM-2 LABOR ORGANIZATION ANNUAL REPORT U.S. Department of Labor Office of Labor-Management Standards Washington, DC 20210 MUST BE USED BY LABOR ORGANIZATIONS WITH $250,000 OR MORE IN TOTAL ANNUAL RECEIPTS AND LABOR ORGANIZATIONS IN TRUSTEESHIP

Form Approved Office of Management and Budget No. 1245-0003 Expires: 10-31-2013

This report is manadatory 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 506-435

2. PERIOD COVERED From 01/01/2012 Through 12/31/2012

3. (a) AMENDED - Is this an amended report: (b) HARDSHIP - Filed under the hardship procedures: (c) TERMINAL - This is a terminal report:

No No No

4. AFFILIATION OR ORGANIZATION NAME UNITE HERE 5. DESIGNATION (Local, Lodge, etc.) LOCAL UNION 7. UNIT NAME (if any) 6. DESIGNATION NBR 17

8. MAILING ADDRESS (Type or print in capital letters) First Name Last Name NANCY GOLDMAN P.O Box - Building and Room Number ROOM 444 Number and Street 312 CENTRAL AVE SE City MINNEAPOLIS State MN ZIP Code + 4 55414

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: Nancy Goldman PRESIDENT 71. SIGNED: Wade Luneberg TREASURER Date: Mar 29, 2013 Telephone Number: 612-379-4730 Date: Mar 29, 2013 Telephone Number: 612-379-4730 Form LM-2 (Revised 2010) ITEMS 10 THROUGH 21 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? 11(a). During the reporting period did the labor organization have a political action committee (PAC) fund? 11(b). During the reporting period did the labor organization have a subsidiary organization as defined in Section X of these Instructions? 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? 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.) 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? 15. During the reporting period did the labor organization acquire or dispose of any assets in a manner other than purchase or sale? 16. Were any of the labor organization's assets pledged as FILE NUMBER: 506-435 20. How many members did the labor organization have at the end 2,888 of the reporting period? 21. What are the labor organization's rates of dues and fees? Rates of Dues and Fees Dues/Fees Amount Unit Minimum Maximum (a) Regular Dues/Fees 0 per Month 39.46 41.46 (b) Working Dues/Fees 0 per 0 0 (c) Initiation Fees 0 per Member 45.35 95.35 (d) Transfer Fees 0 per 0 0 (e) Work Permits 3.00per Shift 0 0

Yes No No Yes No

$500,000

No

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security or encumbered in any way at the end of the reporting period? 17. Did the labor organization have any contingent liabilities at the end of the reporting period? 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? 19. What is the date of the labor organization's next regular election of officers? Form LM-2 (Revised 2010) STATEMENT A - ASSETS AND LIABILITIES

No No No 10/2014

FILE NUMBER: 506-435

ASSETS 22. Cash 23. Accounts Receivable 24. Loans Receivable 25. U.S. Treasury Securities 26. Investments 27. Fixed Assets 28. Other Assets 29. TOTAL ASSETS

Schedule Number 1 2 5 6 7

Start of Reporting Period (A) $83,046

ASSETS

$0 $332,998 $7,348 $423,392

End of Reporting Period (B) $98,843 $0 $0 $0 $215,267 $13,636 $0 $327,746

LIABILITIES LIABILITIES 30. Accounts Payable 31. Loans Payable 32. Mortgages Payable 33. Other Liabilities 34. TOTAL LIABILITIES

Schedule Number 8 9 10

Start of Reporting Period (A)

End of Reporting Period (B)

$0 $0

$0 $0

35. NET ASSETS Form LM-2 (Revised 2010) STATEMENT B - RECEIPTS AND DISBURSEMENTS CASH RECEIPTS 36. Dues and Agency Fees 37. Per Capita Tax 38. Fees, Fines, Assessments, Work Permits 39. Sale of Supplies 40. Interest 41. Dividends 42. Rents 43. Sale of Investments and Fixed Assets 44. Loans Obtained 45. Repayments of Loans Made 46. On Behalf of Affiliates for Transmittal to Them 47. From Members for Disbursement on Their Behalf 48. Other Receipts 49. TOTAL RECEIPTS SCH

$423,392

$327,746

FILE NUMBER: 506-435 AMOUNT CASH DISBURSEMENTS $1,329,521 50. Representational Activities $0 51. Political Activities and Lobbying $412,983 52. Contributions, Gifts, and Grants $0 53. General Overhead $5,419 54. Union Administration $0 55. Benefits $0 56. Per Capita Tax $150,227 57. Strike Benefits 58. Fees, Fines, Assessments, etc. $0 59. Supplies for Resale $0 60. Purchase of Investments and Fixed Assets $0 61. Loans Made $78,256 62. Repayment of Loans Obtained $1,976,406 63. To Affiliates of Funds Collected on Their Behalf 64. On Behalf of Individual Members 65. Direct Taxes SCH 15 16 17 18 19 20 AMOUNT $409,835 $131,539 $60,759 $147,650 $188,967 $184,599 $767,207 $0 $0 $0 $14,431 $0 $0 $0 $55,622
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3 9 2

14

4 2 9

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DOL Form Report (Disclosure)

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66. Subtotal 67. Withholding Taxes and Payroll Deductions 67a. Total Withheld $208,469 67b. Less Total Disbursed $208,469 67c. Total Withheld But Not Disbursed 68. TOTAL DISBURSEMENTS Form LM-2 (Revised 2010) SCHEDULE 1 - ACCOUNTS RECEIVABLE AGING SCHEDULE

$1,960,609

$1,960,609

FILE NUMBER: 506-435 Total Account 90-180 Days 180+ Days Receivable Past Due Past Due (B) (C) (D) $0 $0 $0 $0 $0 $0 Liquidated Account Receivable (E) $0 $0

Entity or Individual Name (A) Total of all itemized accounts receivable Totals from all other accounts receivable Totals(Total of Column (B) will be automatically entered in Item 23, Column(B)) Form LM-2 (Revised 2010) SCHEDULE 2 - LOANS RECEIVABLE 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 regarless of amount. (A) Total of loans not listed above Total of all lines above Totals will be automatically entered in... Form LM-2 (Revised 2010) SCHEDULE 3 - SALE OF INVESTMENTS AND FIXED ASSETS Description (if land or buildings give location) (A) INVESTMENTS INVESTMENTS Total of all lines above Cost (B) Item 24 Column (A) Loans Outstanding at Start of Period (B) Loans Made During Period (C)

FILE NUMBER: 506-435 Repayments Received During Period Cash (D)(1) Other Than Cash (D)(2) Loans Outstanding at End of Period (E)

$0 Item 61

$0 Item 45

$0

$0 Item 69 with Explanation

$0 Item 24 Column (B)

FILE NUMBER: 506-435 Book Value (C) $74,525 $72,630 $147,155 Amount Received (E) $74,525 $75,702 $150,227 $0 $150,227

Gross Sales Price (D) $74,525 $74,525 $72,630 $75,702 $147,155 $150,227 Less Reinvestments (The total from Net Sales Line will be automatically entered in Item 43)Net Sales

Form LM-2 (Revised 2010) SCHEDULE 4 - PURCHASE OF INVESTMENTS AND FIXED ASSETS Description (if land or buildings, give location) (A) COMPUTERS & EQUIPMENT FURNITURE INVESTMENTS Total of all lines above Cost (B) $6,273 $2,750 $5,408 $14,431 Book Value (C) FILE NUMBER: 506-435 Cash Paid (D) $6,273 $2,750 $5,408 $14,431 $0 $14,431

$6,273 $2,750 $5,408 $14,431 Less Reinvestments (The total from Net Purchases Line will be automatically entered in Item 60.)Net Purchases

Form LM-2 (Revised 2010) SCHEDULE 5 - INVESTMENTS Description (A) 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 $215,292 $213,967 FILE NUMBER: 506-435 Amount (B)

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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)) Form LM-2 (Revised 2010) SCHEDULE 6 - FIXED ASSETS Description (A) A. Land (give location) B. Buildings (give location) C. Automobiles and Other Vehicles D. Office Furniture and Equipment E. Other Fixed Assets F. Totals of Lines A through E (Column(D) Total will be automatically entered in Item 27, Column(B)) Form LM-2 (Revised 2003) SCHEDULE 7 - OTHER ASSETS Description (A) Total (Total will be automatically entered in Item 28, Column(B)) Form LM-2 (Revised 2010) SCHEDULE 8 - ACCOUNTS PAYABLE AGING SCHEDULE Entity or Individual Name (A) Total for all itemized accounts payable Total from all other accounts payable Totals (Total for Column(B) will be automatically entered in Item 30, Column(D)) Form LM-2 (Revised 2010) SCHEDULE 9 - LOANS PAYABLE Source of Loans Payable at Any Time During the Reporting Period (A) Total Loans Payable Totals will be automatically entered in... Form LM-2 (Revised 2010) SCHEDULE 10 - OTHER LIABILITIES Description (A) Total Other Liabilities (Total will be automatically entered in Item 33, Column(D)) Form LM-2 (Revised 2010) SCHEDULE 11 - ALL OFFICERS AND DISBURSEMENTS TO OFFICERS (D) Gross Salary Disbursements (before any deductions) $87,902 Schedule 16
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$1,300 $1,300

$215,267

FILE NUMBER: 506-435 Cost or Other Basis (B) $0 $0 $29,516 Total Depreciation or Amount Expensed (C) $0 $15,880 Book Value (D) $0 $0 $13,636 Value (E) $0 $0 $13,636

$29,516

$15,880

$13,636

$13,636

FILE NUMBER: 506-435 Book Value (B) $0

FILE NUMBER: 506-435 Total Account Payable (B) $0 $0 $0 90-180 Days Past Due (C) $0 $0 $0 180+ Days Past Due (D) Liquidated Account Payable (E) $0 $0 $0 $0 $0 $0

FILE NUMBER: 506-435 Loans Owed at Start of Period (B) $0 Item 31 Column (C) Item 44 Loans Obtained During Period (C) $0 Item 62 Repayment During Period Cash (D)(1) $0 Item 69 with Explanation Repayment During Period Other Than Cash (D)(2) $0 Item 31 Column (D) Loans Owed at End of Period (E) $0

FILE NUMBER: 506-435 Amount at End of Period (B) $0

FILE NUMBER: 506-435 (E) Allowances Disbursed (F) (G) Disbursements for Other Official Business Disbursements not reported in (D) through (F) $4,190 (H) TOTAL

(A) Name A Goldman, Nancy B President C C

(B) Title

(C) Status

$92,092

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Schedule 15 Representational Activities

75 % Political Activities and Lobbying

5 % Schedule 17 Contributions $101,702

10 % Schedule 18 General Overhead $3,305 Schedule 18 General Overhead $4,010 Schedule 18 General Overhead $4,637 Schedule 18 General Overhead

5 % Schedule 19 Administration

5%

A Goff, Martin B Senior Vice President C C I Schedule 15 Representational Activities

$105,007 Schedule 19 Administration

Schedule 16 Schedule 17 80 % Political Activities and 10 % Contributions Lobbying $72,331 Schedule 16 85 % Political Activities and Lobbying Schedule 17 Contributions

0%

0%

10 %

A Espinoza, Uriel B Vice President C C I Schedule 15 Representational Activities

$76,341 Schedule 19 Administration

5%

0%

10 %

0%

A Luneberg, Wade B Secretary Treasurer C C I Schedule 15 Representational Activities

$76,108 Schedule 16 Schedule 17 5 % Political Activities and 75 % Contributions Lobbying $700 Schedule 16 Political Activities and Lobbying Schedule 17 Contributions $1,000 Schedule 16 Political Activities and Lobbying Schedule 17 Contributions $1,000 Schedule 16 Political Activities and Lobbying Schedule 17 Contributions $1,200 Schedule 16 Political Activities and Lobbying Schedule 17 Contributions $900 Schedule 16 Political Activities and Lobbying Schedule 17 Contributions $1,584 Schedule 16 Political Activities and Lobbying Schedule 17 Contributions $1,292 Schedule 16 Political Activities and Lobbying Schedule 17 Contributions $345,719 $0

$80,745 Schedule 19 Administration

0%

0%

20 %

A Baker, Claire B Trustee C P I Schedule 15 Representational Activities

$700 Schedule 18 General Overhead Schedule 19 Administration

100 %

A Anderson, Joy B Trustee C C I Schedule 15 Representational Activities

$1,000 Schedule 18 General Overhead Schedule 19 Administration

100 %

A Grajczyk, Cynthia B Trustee C C I Schedule 15 Representational Activities

$1,000 Schedule 18 General Overhead Schedule 19 Administration

100 %

A Dougherty, Michael B Trustee C C I Schedule 15 Representational Activities

$1,200 Schedule 18 General Overhead Schedule 19 Administration

100 %

A Brandel, James B Executive Board C C I Schedule 15 Representational Activities

$900 Schedule 18 General Overhead Schedule 19 Administration

100 %

A Aar, Abdirishid B Executive Board C C I Schedule 15 Representational Activities

$1,584 Schedule 18 General Overhead Schedule 19 Administration

100 %

A Schifsky, Kathleen B Executive Board C C I Schedule 15 Representational Activities

$1,292 Schedule 18 General Overhead $16,142 Schedule 19 Administration $0

100 % $361,861 $361,861

Total Officer Disbursements Less Deductions Net Disbursements Form LM-2 (Revised 2010) SCHEDULE 12 - DISBURSEMENTS TO EMPLOYEES

FILE NUMBER: 506-435

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(A) Name A Peters, Leanne B Accountant C C I

(B) Title

(C) Other Payer

(D) Gross Salary Disbursements (before any deductions) $52,195

(E) Allowances Disbursed

(F) Disbursements for Official Business

(G) Other Disbursements not reported in (D) through (F)

(H) TOTAL

$52,195 Schedule 18 General Overhead $57 Schedule 18 General Overhead $1,383 Schedule 18 General Overhead $3,816 Schedule 18 General Overhead $705 Schedule 18 General Overhead $3,580 Schedule 18 General Overhead $1,832 Schedule 19 Administration Schedule 19 Administration Schedule 19 Administration Schedule 19 Administration $13,486 Schedule 19 Administration Schedule 19 Administration Schedule 19 Administration

Schedule 15 Representational Activities

Schedule 16 Political Activities and Lobbying

Schedule 17 Contributions $52,677

100 %

A Thorson, Martha B Office Manager C C I Schedule 15 Representational Activities Schedule 16 Political Activities and Lobbying

$52,734

Schedule 17 Contributions $32,847

100 %

A Franke, Lyle B Business Representative C C I Schedule 15 Representational Activities Schedule 16 90 % Political Activities and Lobbying

$34,230

Schedule 17 Contributions $49,331

5%

5%

A Valenzuela, Rosalba B Organizer C C I Schedule 15 Representational Activities Schedule 16 95 % Political Activities and Lobbying

$53,147

5%

Schedule 17 Contributions

A Ali, Liban B Business Representative C c I Schedule 15 Representational Activities Schedule 16 95 % Political Activities and Lobbying

$12,781 Schedule 17 Contributions $37,338 Schedule 16 95 % Political Activities and Lobbying Schedule 17 Contributions $17,203

5%

A Mello, Christa B Business Representative C c I Schedule 15 Representational Activities

$40,918

5%

A Munsen, John B Business Representative C c I Schedule 15 Representational Activities

$19,035

Schedule 16 Schedule 17 Schedule 18 95 % Political Activities and Contributions General Overhead Lobbying TOTALS RECEIVED BY EMPLOYEES MAKING LESS $17,592 $1,823 THAN $10000 Schedule 15 Schedule 16 Schedule 17 Schedule 18 I 95 % Representational Activities Political Activities and Lobbying Contributions General Overhead Total Employee Disbursements $271,964 $0 $13,196 Less Deductions Net Disbursements Form LM-2 (Revised 2010) SCHEDULE 13 - MEMBERSHIP STATUS Category of Membership (A) Members Retirees Members (Total of all lines above) Agency Fee Payers* Total Members/Fee Payers *Agency Fee Payers are not considered members of the labor organization. Form LM-2 (Revised 2010)
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5% $19,415

Schedule 19 5% Administration $0 $285,160 $285,160

FILE NUMBER: 506-435 Number (B) 2,887 1 2,888 2,888 Voting Eligibility (C) Yes Yes

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DETAILED SUMMARY PAGE - SCHEDULES 14 THROUGH 19 SCHEDULE 14 OTHER RECEIPTS 1. Named Payer Itemized Receipts 2. Named Payer Non-itemized Receipts 3. All Other Receipts 4. Total Receipts

FILE NUMBER: 506-435 SCHEDULE 17 CONTRIBUTIONS, GIFTS & GRANTS 1. Named Payee Itemized Disbursements 2. Named Payee Non-itemized Disbursements 3. To Officers 4. To Employees 5. All Other Disbursements 6. Total Disbursements SCHEDULE 18 GENERAL OVERHEAD 1. Named Payee Itemized Disbursements 2. Named Payee Non-itemized Disbursements 3. To Officers 4. To Employees 5. All Other Disbursements 6. Total Disbursements SCHEDULE 19 UNION ADMINISTRATION 1. Named Payee Itemized Disbursements 2. Named Payee Non-itemized Disbursements 3. To Officers 4. To Employees 5. All Other Disbursements 6. Total Disbursements

$40,000 $0 $38,256 $78,256

$21,875 $4,750 $9,209 $0 $24,925 $60,759

SCHEDULE 15 REPRESENTATIONAL ACTIVITIES 1. Named Payee Itemized Disbursements $0 2. Named Payee Non-itemized Disbursements $15,402 3. To Officers $222,002 4. To Employees $169,508 5. All Other Disbursements $2,923 6. Total Disbursements $409,835 SCHEDULE 16 POLITICAL ACTIVITIES AND LOBBYING 1. Named Payee Itemized Disbursements $48,500 2. Named Payee Non-itemized Disbursements $0 3. To Officers $79,482 4. To Employees $2,657 5. All Other Disbursements $900 6. Total Disbursement $131,539 Form LM-2 (Revised 2010) SCHEDULE 14 - OTHER RECEIPTS Name and Address (A) UNITE HERE Tip State & Local Fund 275 Seventh Avenue, 11th Fl New York NY 10001 Type or Classification (B) PAC FUND Form LM-2 (Revised 2010)

$0 $73,396 $12,239 $1,712 $60,303 $147,650 $9,973 $16,014 $38,931 $111,284 $12,765 $188,967

FILE NUMBER: 506-435

Purpose (C) Reimbursement 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

Date (D) 09/01/2012

Amount (E) $40,000 $40,000 $40,000

SCHEDULE 15 - REPRESENTATIONAL ACTIVITIES Name and Address (A) Metcalf, Kaspari, Engdahl, Lazarus PA 1660 South Highway 100 Minneapolis MN 55416-1531 Type or Classification (B) Legal Form LM-2 (Revised 2010)

FILE NUMBER: 506-435

Purpose (C) 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

Date (D)

Amount (E) $15,402 $15,402

SCHEDULE 16 - POLITICAL ACTIVITIES AND LOBBYING Name and Address (A) Wilhelmi Government Affairs Inc 819 Everett Drive Stillwater MN 55082

FILE NUMBER 506-435

Purpose (C) Lobbying Lobbying Lobbying Total Itemized Transactions with this Payee/Payer

Date (D) 01/19/2012 06/12/2012 08/15/2012

Amount (E) $20,000 $9,800 $18,700 $48,500

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Type or Classification (B) Lobbying Form LM-2 (Revised 2010)

Total Non-Itemized Transactions with this Payee/Payer Total of All Transactions with this Payee/Payer for This Schedule $48,500

SCHEDULE 17 - CONTRIBUTIONS, GIFTS & GRANTS Name and Address (A) Jobs Now Coalition 400 Selby Avenue Suite Q Saint Paul MN 55102 Type or Classification (B) Charity Name and Address (A) Supervalue Inc 250 E Parkcenter Boulevard Boise ID 83726 Type or Classification (B) Grocery Store Name and Address (A) UNITE HERE Relief Fund 275 7th Avenue New York NY 10001 Type or Classification (B) Charity Form LM-2 (Revised 2010) SCHEDULE 18 - GENERAL OVERHEAD Name and Address (A) Betts & Hayes, Ltd. 801 Meander Court Medina MN 55340 Type or Classification (B) Accounting Name and Address (A) Century Link 398 Northtown Drive NE Blaine MN 55434 Type or Classification (B) Telephone Name and Address

FILE NUMBER: 506-435

Purpose (C) Donation 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

Date (D) 02/14/2012

Amount (E) $5,000 $5,000 $5,000

Purpose (C) Gift Cards 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

Date (D) 11/08/2012

Amount (E) $11,875 $11,875 $4,750 $16,625

Purpose (C) Donation 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

Date (D) 11/06/2012

Amount (E) $5,000 $5,000 $5,000

FILE NUMBER: 506-435

Purpose (C) 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

Date (D)

Amount (E) $6,068 $6,068

Purpose (C) 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

Date (D)

Amount (E) $8,971 $8,971

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(A) Labor Temple Assoc RE Holdings PO Box 86 SDS-12-2659 Minneapolis MN 55486 Type or Classification (B) Rent Name and Address (A) Lavigne Consulting Corp 1730 New Brighton Boulevard Minneapolis MN 55413 Type or Classification (B) Consulting Form LM-2 (Revised 2010) SCHEDULE 19 - UNION ADMINISTRATION Name and Address (A) Millenium Hotel 1313 Nicollet Mall Minneapolis MN 55403 Type or Classification (B) Hotel Name and Address (A) Seven Corners Printing 1099 Snelling Ave North St Paul MN 55108 Type or Classification (B) Printing Form LM-2 (Revised 2010) SCHEDULE 20 - BENEFITS Description (A)

Purpose (C) 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

Date (D)

Amount (E) $51,513 $51,513

Purpose (C) 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

Date (D)

Amount (E) $6,844 $6,844

FILE NUMBER: 506-435

Purpose (C) Banquet 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

Date (D) 12/21/2012

Amount (E) $9,973 $9,973 $9,973

Purpose (C) 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

Date (D)

Amount (E) $16,014 $16,014

FILE NUMBER: 506-435 To Whom Paid (B) Local 153 Pension Fund Consolidated Retirement Fund National Plus Plan John Munsen Health Partners Hotel Trust Fund Standard Insurance Company Leanne Peters Amount (C) $4,354 $78,226 $3,720 $4,721 $64,985 $23,592 $4,735 $266 $184,599

Pension Pension 401K Employer Match Health Insurance Health & Dental Insurance Health & Welfare Life & Disability Insurance Dependent Health Insurance Total of all lines above (Total will be automatically entered in Item 55.) Form LM-2 (Revised 2010) 69. ADDITIONAL INFORMATION SUMMARY

FILE NUMBER: 506-435

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Question 12: Betts & Hayes, LTD 801 Meander Court Medina, MN 55340 Question 10: Hotel Trust Fund Wilson McShane Corporation 3001 Metro Drive Suite 500 Bloomington, MN 55425 Statement A, Accounts Receivable Begin Total: No change made. Schedule 13, Row1:Members - pay full dues. Schedule 13, Row1: Schedule 13, Row2:Retirees - pay full dues Schedule 13, Row2: Form LM-2 (Revised 2010)

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