Form Lm-10 - Employer Report Form - U.s. Department Of Labor

Download a blank fillable Form Lm-10 - Employer Report Form - U.s. Department Of Labor in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Lm-10 - Employer Report Form - U.s. Department Of Labor with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

U.S. Department of Labor

FORM LM-10

Form approved

Office of Labor-Management

Office of Management

Standards

and Budget

EMPLOYER 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,

For Official Use Only

fines, or civil penalties as provided by 29 U.S.C. 439 or 440.

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT

Part A

Month/Day/Year

2. Fiscal Year

1. File Number E-

(mm/dd/yyyy)

Covered

From:

Through:

3. Name and address of Reporting Employer (inc. trade name, if any).

4. Name and address of President or corresponding principal officer, if

different from address in Item 3.

Employer

Name

Trade Name

Attention To

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

Title

Street

Mailing Address

City

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

ZIP Code + 4

Street

State

City

State

ZIP Code + 4

5. Any other address where records necessary to verify this report will be

6. Indicate by checking the appropriate box or boxes where records

available for examination.

necessary to verify this report will be available for examination.

Address in Item 3

Name

Title

Address in Item 4

Organization

Address in Item 5

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

Street

City

State

ZIP Code + 4

7. Type of organization.

Corporation

Partnership

Individual

Other (specify)

Signatures

Each of the undersigned, duly authorized officers of the above employer 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 VIII on penalties in the instructions.)

14. Signed

President

Treasurer

13. Signed

(if other title, see

instructions)

Title

President

Treasurer

Telephone Number

Date