Form Lm-21 - Receipts And Disbursements Report

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FORM LM-21
U.S. Department of Labor
Form approved
Office of Labor-Management
Office of Management
Standards
and Budget
RECEIPTS AND DISBURSEMENTS 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 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 Relations and Disclosure Act of 1959, as amended. (LMRDA)
For Official Use Only
READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT
E
Month/Day/Year
Month/Day/Year
2. Period Covered
1 . File Number C-
( mm/dd/yyyy )
( mm/dd/yyyy )
By This Report
From:
Through:
A. Person Filing
3. Name and mailing address (include ZIP Code):
4. Any other address where records necessary to verify this report are kept:
Name
Name
Title
Title
Organization
Organization
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
State
ZIP Code + 4
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 the Section on penalties in the instructions).
17. Signed
President
18. Signed
Treasurer
(If other title, see
(if other title, see
President
Treasurer
Title
Title
instructions)
instructions)
On
On
Date
Telephone Number
Telephone Number
Date
Print Report
Form LM-21 (2003)
Page 1 of 2

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