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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-491160

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1. LABORERS INTERNATIONAL UNION OF NORTH AMERICA - LOCAL NO. 91 POLITICAL ACTION FUND

    NOTE:Commmittee Name is different than previously reported

    2556 SENECA AVENUE
    NIAGARA FALLS, NY 14305
    Email: nsims@roadrunner.com

2. Date: 09/01/2010

3. FEC Committee ID #: C00155069 This committee is a separate segregated fund. Its connected organization is a Labor Organization

Affiliated Committees/Organizations

Laborers' International Union of North America - Local No. 91
2556 Seneca Ave.
Niagara Falls, New York 14305
Affiliated Relationship Code: Connected Organization

Laborers' International Union of North
905 16th Street NW
Washington, DC 20006
Affiliated Relationship Code: Affiliated Committee

Custodian of Records:

MATT SCHIAVI
649 SARA COURT
LEWISTON, NY 14092
Title: Secretary-Treasurer
Phone # (716) 297-6441

Treasurer:

MATT SCHIAVI
649 SARA COURT
LEWISTON, New York 14092
Title: Secretary-Treasurer
Phone # (716) 297-6441

Designated Agent(s):

RICHARD PALLADINO
7657 HIGHLAND DR
GASPORT, New York 14067
Title: Business Manager
Phone # (716) 297-6441

Banks or Depositories

M&T Bank
750 Main Street
Niagara Falls, New York 14301

Signed: MATT SCHIAVI
Date Signed: 09/01/2010

(End FEC FORM 1)

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