Form Lm-20 - Agreement And Activities Report Form - U.s. Department Of Labor

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FORM LM-20
U.S. Department of Labor
Form approved
Office of Labor-Management
Office of Management
Standards
and Budget
AGREEMENT AND ACTIVITIES 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
For Official Use Only
penalties as provided by 29 U.S.C. 439 or 440. Required of persons, including Labor Relations Consultants and Other Individuals
and Organizations, Under Section 203(b) of the Labor-Management Reporting and Disclosure Act of 1959, as amended. (LMRDA)
READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.
E
1. File Number:
C-
Person Filing
2. Name and mailing address (include ZIP Code):
3. Any other address where records necessary to verify this report are kept:
Name
Name
Title
Title
Organization
Organization
P.O. Box, Bldg., Room No., if any
P.O. Box, Bldg., Room No., if any
Street
Street
City
City
State
ZIP Code + 4
State
ZIP Code + 4
5. Type of person:
4. Date fiscal year ends:
a.
Individual
b.
Partnership
c.
Corporation
d.
Other (Specify):
Nature of Agreement or Arrangement
7. Date entered into:
6. Full name and address of employer with whom made (include ZIP Code):
Name
8. Name of person(s) through whom made:
Organization
Name
Trade Name, if any
Name
P.O. Box, Bldg., Room No., if any
Name
Street
City
Name
State
ZIP Code + 4
Name
Signatures
Each of 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. (See Section VII on penalties in the instructions.)
13. Signed
President
14. Signed
Treasurer
(If other title, see
(If other title, see
instructions)
instructions)
President
Treasurer
Title
Title
On
On
Telephone Number
Date
Telephone Number
Date
Form LM-20 (2003)
Page 1 of 2
Print Report
Page 1 of 2

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