LM-30 Form LM-30 Labor Organization Officer and Employee Repor

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

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

FORM LM-30
LABOR ORGANIZATION OFFICER AND
EMPLOYEE REPORT

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
READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.
E

2. Fiscal Year Covered From:

1. File Number U -

Through:
3. Name and address of person filing.

4. Name, file number, and address of labor organization.

Name

Name
Labor Organization File Number

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

P.O. Box, Building and Room Number, if any

Street

Street

City

City

State

ZIP Code + 4

State

ZIP Code + 4

5. Position in labor organization.

Enter appropriate data below If, during the past fiscal year, you or your spouse or minor child directly or indirectly had any of the following interests
(except as specified in the exclusions set forth in the instructions):
A. Held an interest in, engaged in transactions (including loans) with, or derived income or other economic benefit of
monetary value from an employer whose employees your organization represents or is actively seeking to represent.
6. Name and address of Employer (including trade name, if any).

Add New Part A

7.a. Nature of Interest, Transaction, or Income.

Name
Trade Name, if any:
P.O. Box, Bldg., Room No., if any
7.b. Amount.
Street
City
State

ZIP Code + 4
Signature

15. Signature and verification. The undersigned declares, under penalty of Perjury and other applicable penalties of the 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.)

Signed

On
Date

Form LM-30 (2003)

Print Report

Telephone Number
Page 1 of 2

File Number U-

Name of Person Filing
B. Held an interest in or derived income or economic benefit with monetary value from a business (1) a
substantial part of which consists of buying from, selling or leasing to, or otherwise dealing with the business
of an employer whose employees your labor organization represents or is actively seeking to represent, or
(2) any part of which consists of buying from or selling or leasing directly or indirectly to, or otherwise
dealing with your labor organization or with a trust in which your labor organization is interested.
8. Name and address of Business (including trade name, if any).

Add New Part B

9. Business deals with:

Name
a. Labor Organization
Trade Name, if any:
b. Trust
P.O. Box, Bldg., Room No., if any

c. Employer

Street
City
State

ZIP Code + 4
11.a. Nature of such dealing.

10. If 9.b. or 9.c. is checked give trust or employer's name.
Name
Trade Name, if any:
P.O. Box, Bldg., Room No., if any
Street

11.b. Approximate dollar value of such dealing.

City
State

12.a. Nature of interest held or income received.
ZIP Code + 4

12.b. Amount.
C. Received from any employer (other than an employer covered under parts A and B above)
or from any labor relations consultant to an employer any payment of money or other thing of value.

Add New Part C

14.a. Nature of payment.

13.a. Name and address of Employer or Labor Relations Consultant
(including trade name, if any).
Name
Trade Name, if any:
P.O. Box, Bldg., Room No., if any
Street
City
State

13.b. Is the Business an Employer
Form LM-30 (2003)

ZIP Code + 4

or Consultant

?

14.b. Amount of payment.

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