Certification
We, the undersigned, duly authorized officers of [name of national organization], hereby certify that the local labor organizations individually listed on the attached documents come within the purview of 29 CFR 403.4(b) for the reporting period from [beginning date of national organization's fiscal year] through [ending date of national organization's fiscal year], namely:
(1) they are local labor organizations; (2) they are not in trusteeship; (3) they have no assets, liabilities, receipts, or disbursements; (4) they are governed by a uniform constitution and bylaws, and fifty copies of the most recent uniform constitution and bylaws have been filed with the Office of Labor-Management Standards; (5) they have no governing rules of their own; and (6) they are subject to the following uniform schedule of fees and dues: [specify schedule for dues, initiation fees, fees required from transfer members, and work permit fees, as applicable].
Each document attached contains the specific information called for in 29 CFR 403.4(b)(3)(i)-(v) , namely: (i) the local labor organization's name and designation number; (ii) the file number assigned the organization by the Office of Labor-Management Standards; (iii) the local labor organization's mailing address; (iv) the beginning and ending date of the reporting period; and (v) the names and titles of the president and treasurer or corresponding principal officers of the local labor organization as of [the ending date of the national organization's fiscal year].
Furthermore, we certify that the terminal reports required by 29 CFR 403.4(b)(5) and 29 CFR 403.5(a) have been filed for any local labor organizations which have lost their identity through merger, consolidation, or otherwise on whose behalf a simplified annual report was filed for the last reporting period.
(Format for Simplified Annual Reporting)
simplified annual report
Affiliation name:
_______________________________
Designation name and number:
_______________________________
Unit name:
_______________________________
Mailing address:
_______________________________
Name of person:
_______________________________
Number and street:
_______________________________
City, State and zip:
_______________________________
File number:
_______________________________
Period covered:
_______________________________
From Through
_______________________________
Names and Titles of president and treasurer or corresponding principal officers
_______________________________
For certification see NHQ file folder file number:
President _______________________________
Where signed _______________________________
Date _______________________________
Treasurer _______________________________
Where signed _______________________________
Date_______________________________
29 C.F.R. §403.4