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Kansas Secretary of State Ron Thornburgh Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 (785) 296-2239 [email protected] www.kssos.org Check one: Labor organization Employee organization Agricultural organization Report is for the period ending
Month Day

KANSAS SECRETARY OF STATE

Labor / Employee Organization Annual Report

LA
67-01

All information must be completed or this document will not be accepted for filing.

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If the organization has less than 100 members as of the close of the reporting period, no report needs to be filed.

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Name of organization: Address: Number of members:

Street address

City

State

Zip

Date of regular election of officers:
Month Day Year

1. Names, titles and addresses of officers and registered business agents: Name Title Street address City State Zip

2. Salaries, wages, bonuses, and other remuneration paid to officers and registered business agents: Name Salaries, wages Bonuses Other remuneration

3. Rate of initiation fees, dues, assessments and other charges to members: Initiation fees, per member Dues, per member $ $ $ Work permit fees Other periodic payments $

Transfer fees, per member $ Other charges per member $

I state that this report and the audited statement of income, expenditures, assets and liabilities are true and correct to the best of my knowledge.

Signature

Title

Page 1 of 2

Financial Statement
(Audited Statement of Income, Assets, Expenditures and Liabilities)
Income 1) Initiation fees 2) Dues 3) Per capita tax 4) Fees 5) Fines 6) Work permits 7) Other payments from members 8) Interest 9) Loans obtained 10) Other income (specify) 11) TOTAL INCOME Assets 12) Land 13) Buildings (Less depreciation, if any) 14) Office equipment (Less depreciation, if any) 15) Other personal property (Less depreciation, if any) 16) Cash on hand 17) Cash in banks 18) Accounts, loans receivable 19) Investments 20) Other assets (specify) 21) TOTAL ASSETS $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Resources Amount $ $ $ $ $ $ $ $ $ $ $ Total

Expenditures and Liabilities
Expenditures 22) Wages, salaries, bonuses, gross (Less deductions) 23) Per capita tax 24) Fines, fees, assessments, etc. 25) Office expense 26) Contributions and gifts 27) Loans made 28) Taxes 29) Purchase of personal property or real estate 30) Other expenditures (specify) 31) TOTAL EXPENDITURES Liabilities 32) Accounts payable 33) Notes payable 34) Encumbrances on real estate 35) Other liabilities (specify) 36) TOTAL LIABILITIES $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Instructions Submit this form with a $25 filing fee. Notice: There is a $25 service fee for all returned checks.
Rev. 8/11/03 amc K.S.A. 44-806 Page 2 of 2