Form Lm-30 - Labor Organization Officer And Employee Report printable pdf download

U.S. Department of Labor

FORM LM-30

Form Approved

Office of Labor-Management Standards

Office of Management and Budget

Washington, DC 20210

No. 1245-0005

LABOR ORGANIZATION OFFICER AND EMPLOYEE REPORT

Expires 09-30-2014

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 BEFORE PREPARING THIS REPORT

5. Labor Organization Identifying Information

Name

U-

1. LM-30 File Number:

_______________

2. Fiscal Year Covered: from _______________

through _______________

Street address

(mm/dd/yyyy)

3. Amended Report – If this is an amended report, check here:

City

State

ZIP

4. Your Contact Information

Name (first, middle, last)

File number

Street address

Officer

Employee

City

State

ZIP

Your officer position or job title

Email address (optional)

Complete PART A, B, or C if, during the past fiscal year, you or your spouse or minor child directly or indirectly had a reportable interest in, transaction or arrangement with,

or received income, payment, or benefit from the entities described below.

PART A – REPRESENTED EMPLOYER. An employer whose employees your labor organization represents or is actively seeking to represent.

7.a. Nature of interest, transaction, benefit, arrangement, income, or loan

6. Name of represented employer _______________________________________________________

Contact name ___________________________________________ Telephone __________________

Street address _____________________________________________________________________

7.b. Amount or value of interest, transaction, benefit, arrangement, income, or loan

City ____________________________________ State ___________ ZIP ______________________

15. Signature and Verification

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.

Signed ______________________________________________________

On ______________________

Telephone Number ______________________________

Date (mm/dd/yyyy)

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Form LM-30 (Revised 2011)