Form Lm-21 - Receipts And Disbursements Report Page 2
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2File Number C-
Name of Person Filing:
B. Statement of Receipts Report all receipts from employers in connection with labor relations advice or services regardless of the purposes of the advice
or services.
5.a. Name and Address of Employer (including trade name, if any).
Mailing Address:
P.O. Box, Building and Room Number, if any
Employer
Street
Trade Name
Attention To
City
State
ZIP Code + 4
Title
5.b. Termination Date
5.c. Amount
6. TOTAL RECEIPTS FROM ALL EMPLOYERS
Additional Employer Addresses
C. Statement of Disbursements
Report all disbursements made by the reporting organization in connection with labor relations advice or services rendered
to the employers listed in Part B.
7. Disbursements to Officers and Employees:
(b) Salary
(c) Expenses (d) Totals
(a) Name
9. Office and Administrative Expenses
10. Publicity
11. Fees for Professional Services
12. Loans Made
13. Other Disbursements
8. Total disbursements to officers and employees:
14. Total Disbursements (Sum of Items 8-13)
Additional Officers & Employees
D. Schedule of Disbursements for Reportable Activity
Use this Schedule to report only disbursements made for the purposes described in Part D of the
instructions.
15.b. Trade Name, If any:
15.a. Employer Name:
15.d. Amount
15.c. To Whom Paid
Name
15.e. Purpose
Title
Organization
P.O. Box, Building and Room Number, if any
Street
City
ZIP Code + 4
State
Washington
16. TOTAL DISBURSEMENTS FOR ALL REPORTABLE ACTIVITY
Form LM-21 (2003)
Page 2 of 2
Additional Reportable Activities
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