Form Lm-30 - Labor Organization Officer And Employee Report

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U.S. Department of Labor

Form approved

FORM LM-30

Office of Labor-Management

Office of Management

and Budget

Standards

LABOR ORGANIZATION OFFICER AND

No. 1215-0188

Washington, DC 20210

Expires 11-30-2006

Expires 11-30-2009

EMPLOYEE REPORT

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

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.

2. Fiscal Year Covered From:

1. File Number U -

Through:

3. Name and address of person filing.

4. Name, file number, and address of labor organization.

Name

Labor Organization File Number

P.O. Box, Bldg., Room No., if any

P.O. Box, Building and Room Number, if any

Street

City

State

ZIP Code + 4

State

ZIP Code + 4

5. Position in labor organization.

Enter appropriate data below If, during the past fiscal year, you or your spouse or minor child directly or indirectly had any of the following interests

(except as specified in the exclusions set forth in the instructions):

A. Held an interest in, engaged in transactions (including loans) with, or derived income or other economic benefit of

Add New Part A

monetary value from an employer whose employees your organization represents or is actively seeking to represent.

7.a. Nature of Interest, Transaction, or Income.

6. Name and address of Employer (including trade name, if any).

Name

Trade Name, if any:

P.O. Box, Bldg., Room No., if any

7.b. Amount.

Street

City

State

ZIP Code + 4

Signature

15. Signature and verification. The undersigned declares, under penalty of Perjury and other applicable penalties of the 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. (See the section on penalties in the instructions.)

Signed

Date

Telephone Number

Form LM-30 (2003)

Print Report

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