Form Lm-10 - Employer Report Form - U.s. Department Of Labor Page 3
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1
2
3Part B
Name of Reporting Employer:
File Number E-
Check Item Number (from Page 2)
ITEM 8.a
ITEM 8.b
ITEM 8.c
ITEM 8.d
ITEM 8.e
ITEM 8.f
to which this Part B applies
9.c. Position In labor organization or with employer (if an independent
9.a.
Agreement
Payment
Both
labor consultant, so state).
9.d. Name and address of firm or labor organization with whom
9.b. Name and address of person with whom or through whom a
employed or affiliated.
separate agreement was made or to whom payments were
made.
Organization
Name
P.O. Box, Building and Room Number, if any
P.O. Box, Building and Room Number, if any
Street
Street
City
City
State
ZIP Code + 4
ZIP Code + 4
State
10.b. The promise, agreement, or arrangement was:
10.a. Date of the promise, agreement, or arrangement pursuant to
which payments or expenditures were agreed to or made.
Written*
Oral
Both
(*Written agreements entered into during the fiscal year must be attached.)
11.a. Date of each payment or
11.b. Amount of each payment
11.c. Kind of each payment or expenditure (Specify whether
or expenditure
payment or loan, and whether in cash or property)
expenditure ( mm/dd/yyyy ).
Continuation page for Item 11
12. Explain fully the circumstances of all payments, including the terms of any oral agreement or understanding pursuant to which they were made.
Form LM-10 - Part B (2003)
Page 3 of 3
Add More Item 12 Information
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