Form Lm-30 Labor Organization Officer And Employee Annual Report

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U.S. Department of Labor

Form Approved

FORM LM-30 LABOR ORGANIZATION

Employment Standards Administration

Office of Management

Office of Labor-Management Standards

and Budget

OFFICER AND EMPLOYEE ANNUAL REPORT

Washington, DC 20210

No. 1215-0188

Expires 12/31/2010

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.

For Official Use Only

PLEASE READ THE INSTRUCTIONS CAREFULLY, ESPECIALLY PART IX (PAGES 14 - 18), BEFORE PREPARING

THIS REPORT. YOU ARE NOT REQUIRED TO FILE THIS REPORT UNLESS YOU, YOUR SPOUSE, OR MINOR

CHILD HAVE RECEIVED A PAYMENT, ENGAGED IN ANY TRANSACTIONS OR ARRANGEMENTS OR HELD AN

INTEREST OF THE TYPES DESCRIBED IN PART II OF THE INSTRUCTIONS (PAGES 1 - 9).

Add Item 4 Page

PART A

4. LABOR ORGANIZATION IDENTIFYING INFORMATION:

2. PERIOD COVERED:

Month/Day/Year

A. NAME

1. LM-30 FILE NUMBER:

- ___________

(mm/dd/yyyy)

FROM

THROUGH

B. MAILING ADDRESS (LINE 1)

3. CONTACT INFORMATION OF REPORTING PERSON:

C. MAILING ADDRESS (LINE 2)

A. FIRST NAME

B. MIDDLE NAME

C. LAST NAME

D. MAILING ADDRESS (LINE 1)

D. CITY

STATE

ZIP CODE

E. MAILING ADDRESS (LINE 2)

E. FILE NUMBER

F. CITY

G. STATE

H. ZIP CODE

F. OFFICER

EMPLOYEE

G. YOUR OFFICER POSITION OR JOB TITLE

I. EMAIL ADDRESS (optional)

H. DID YOU HOLD THIS POSITION OR JOB TITLE AT THE END OF

THE REPORTING PERIOD?

YES

5. SUMMARY (FROM ATTACHED PART B)

A. TOTAL REPORTED INCOME OR OTHER PAYMENTS (total from Schedule 2, Item F, Column (1) of each Part B)

B. TOTAL REPORTED ASSETS (total from Schedule 2, Item F, Column (2) of each Part B)

THE UNDERSIGNED DECLARES, UNDER PENALTY OF PERJURY AND OTHER APPLICABLE PENALTIES OF LAW, THAT ALL OF THE INFORMATION SUBMITTED IN THIS REPORT (INCLUDING

THE INFORMATION CONTAINED IN ANY ACCOMPANYING DOCUMENTS) HAS BEEN EXAMINED BY THE SIGNATORY AND IS, TO THE BEST OF THE UNDERSIGNED'S KNOWLEDGE AND

BELIEF, TRUE, CORRECT AND COMPLETE.

8. SIGNED

Date (mm/dd/yyyy)

Telephone Number

Form LM-30 (Revised 2007)

Page 1 of 9

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