Form LM-4 Form LM-4 Labor Organization Annual Report

U.S. Department of Labor
Employment Standards Administration
Office of Labor-Management Standards
Washington, DC 20210

FORM LM-4 LABOR ORGANIZATION ANNUAL REPORT
FOR USE ONLY BY LABOR ORGANIZATIONS WITH LESS THAN $10,000 IN TOTAL ANNUAL RECEIPTS

Form Approved
Office of Management and Budget
No. 1215-0188
Expires: 11-30-2006

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.
READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT
For Official Use Only

1. FILE NUMBER

2. PERIOD COVERED
MON
DAY

3. (a) AMENDED – If this is an amended report correcting a previously filed
report, check here:

YEAR

(b) TERMINAL – If your organization ceased to exist and this is its terminal
report, see section XII of the instructions and check here:

From
Through
4. AFFILIATION OR ORGANIZATION NAME
5. DESIGNATION (Local, Lodge, etc.)

8. MAILING ADDRESS (Type or print in capital letters)
First Name
Last Name
6. DESIGNATION NUMBER
P.O. Box – Building and Room Number (if any)

7. UNIT NAME (if any)
Number and Street
City
State

ZIP Code + 4

19. ADDITIONAL INFORMATION

Each of the undersigned, duly authorized officers of the above labor organization, 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 VI on penalties in the instructions.)
20.SIGNED:

21. SIGNED:

__________________________________________

________________________ ________________________
Date
Form LM-4 (Revised 2000)

Telephone Number

(If other title, see
instructions.)

___________________________________________

________________________ ________________________
Date

Telephone Number

(If other title, see
instructions.)

COMPLETE ITEMS 9 THROUGH 18

FILE NUMBER:

Enter Amounts in Dollars Only – Do Not Enter Cents

9. During the reporting period did the labor organization have any changes 14. Enter the total value of your organization’s assets at
the end of the reporting period (cash, bank accounts,
in its constitution and bylaws, other than the rates of dues and fees, or in
equipment, etc).
practices/procedures listed in the instructions? (If the constitution and
bylaws have changed, attach two new dated copies. If practices/
procedures have changed, see instructions.)
15. Enter the total liabilities (debts) of your organization
Yes
No
at the end of the reporting period (unpaid bills, loans
owed, etc.).
10. During the reporting period did the labor organization change the rates
of dues and fees? (If “Yes”, report the new rates in Item 19 on page 1.)
16. Enter the total receipts of your organization during
Yes
No
the reporting period (dues, fees, interest received, etc.).
(If $10,000 or more, your organization must file form
LM-2 or LM-3 instead of this form.)
11. During the reporting period did the labor organization discover any loss
or shortage of funds or other assets? (Answer “Yes” even if there has been
repayment or recovery.)?
17. Enter the total disbursements made by your
Yes

No

12. During the reporting period was your organization insured by a fidelity
bond?
Yes

organization during the reporting period (per capita tax,
loans made, net payments to officers, payments for
office supplies, etc.)

No

If “Yes”, enter the maximum amount recoverable under the bond loss
caused by any person.

13. How many members did your organization have at the end of the
reporting period?

18. Enter the total payments to officers and employees
during the reporting period (gross salaries, lost time
payments, allowances, expenses, etc.).

Please be sure to:
• Enter your union’s 6-digit file number in Item 1.
• Report a time period of no more than one year in Item 2.
• Have your union’s president and treasurer sign the Form LM-4 in Items
20 and 21.
• FILE ON TIME. Form LM-4 must be filed within 90 days after the end of
your union’s fiscal year.

If the answer to question 9, 10, or 11 is "Yes," provide details in Item 19 (Additional Information) as explained in the instructions for each item.
Form LM-4 (Revised 2000)

19. ADDITIONAL INFORMATION

Form LM-4 (Revised 2000)

FILE NUMBER: