LM-20 Form LM-20 Agreement and Activities Report

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

FORM LM-20
AGREEMENT AND ACTIVITIES REPORT

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. Required of persons, including Labor Relations Consultants and Other Individuals
and Organizations, Under Section 203(b) of the Labor-Management Reporting and Disclosure Act of 1959, as amended. (LMRDA)

For Official Use Only

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.

E

1. File Number:

C-

Person Filing
2. Name and mailing address (include ZIP Code):

3. Any other address where records necessary to verify this report are kept:

Name

Name

Title

Title

Organization

Organization

P.O. Box, Bldg., Room No., if any

P.O. Box, Bldg., Room No., if any

Street

Street

City

City
ZIP Code + 4

State
4. Date fiscal year ends:

State

ZIP Code + 4

5. Type of person:
a.

Individual

b.

Partnership

c.

Corporation

d.

Other (Specify):

Nature of Agreement or Arrangement
6. Full name and address of employer with whom made (include ZIP Code):

7. Date entered into:

Name
8. Name of person(s) through whom made:

Organization

Name

Trade Name, if any
P.O. Box, Bldg., Room No., if any

Name

Street

Name

City

Name
ZIP Code + 4

State

Name
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 Section VII on penalties in the instructions.)
13. Signed
Title

President
(If other title, see
instructions)

President

Title

On

Treasurer
(If other title, see
instructions)

Treasurer

On
Date

Form LM-20 (2003)

14. Signed

Date

Telephone Number

Print Report

Telephone Number
Page 11 of
of 22
Page

File Number C-

Filer:

9. Check the appropriate box to indicate whether an object of the activities undertaken, is directly or indirectly:

a.

To persuade employees to exercise or not to exercise, or persuade employees as to the manner of exercising, the right to organize and bargain
collectively through representatives of their own choosing.

b.

To supply an employer with information concerning the activities of employees or a labor organization in connection with a labor dispute involving
such employer, except information for use solely in conjunction with an administrative or arbitral proceeding or a criminal or civil judicial proceeding.

10. Terms and conditions (Explain in detail; see instructions. Written agreements must be attached.):

Add Additional Activity (Item 11)

Specific Activities to be Performed
11. For each activity, separately list in detail the information required (See instructions):
a. Nature of activity:

11.b. Period during which performed:

11.c. Extent performed:

11.d. Name and address through whom performed:

Additional Name and address through whom performed, if any:

Name

Name

Organization

Organization

P.O. Box, Bldg., Room No., if any

P.O. Box, Bldg., Room No., if any

Street

Street

City

City

State

ZIP Code + 4

State

ZIP Code + 4

Add More Names (Item 11.d.)
12.a. Identify subject groups of employees:

Form LM-20 (2003)

12.b. Identify subject labor organizations:

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