LM-10 Form LM-10 Employer Report

L M-10

EMPLOYER REPORT

OMB No. XXXX-XXXX. Expires XX-XX-XXXX.

IMPORTANT: 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.

O

For Official Use Only

E

ffice of Labor-Management Standards

U.S. Department of Labor

 Read the instructions carefully before completing this report. 

1.a. File Number E-	1.b.  Hardship Exemption	1.c.  Amended Report	2. Fiscal Year Covered: ____________­­____ through ________________ (mm/dd/yyyy) (mm/dd/yyyy)
3. Name and address of Reporting Employer (including trade name, if any). Employer Attention To (including title) Street City State ZIP Code Email Address Employer Identification Number (EIN) __________________________			4. Name of President or corresponding principal officer and address if different from address in Item 3. Name Title Street City State ZIP Code Email Address
5. Any other address where records necessary to verify this report will be available for examination. Name Title Organization Street City State ZIP Code Email Address			6. Indicate by checking the appropriate box or boxes where records necessary to verify this report will be available for examination.  Address in Item 3  Address in Item 4  Address in Item 5
			7. Type of organization.  Corporation  Partnership  Individual  Other (specify)

Signatures

Each of the undersigned, duly authorized officers of the above employer 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 VIII on penalties in the instructions.)
18. Signed President (If other title, see instructions.)	19. Signed Treasurer (If other title, see instructions.)
On Date (mm/dd/yyyy) Telephone Number	On Date (mm/dd/yyyy) Telephone Number

Form LM-10 (XXXX) Page 1 of 4

PART A – Payments to Unions and Union Officials. You must complete Part A if you made or promised or agreed to make, directly or indirectly, any payment or loan of money or other thing of value (including reimbursed expenses) to any labor organization or to any officer, agent, shop steward, or other representative or employee of any labor organization.
8. Name of Recipient/Contact Name________________________________ Labor Organization  Individual recipient  Labor organization recipient Street ______________________________________________ City____________________________ State _______ ZIP Code __________________ Telephone _________________________________ Email Address If the address of the labor organization differs from that of the individual recipient of the payment or the contact person for the labor organization, click here: [Continuation button]
9.a. Date of each payment. (mm/dd/yyyy)	9.b. Amount of each payment.	9.c. Kind of payment. (Specify if payment or loan, and if in cash or property.)	9.d. Explain fully the circumstances of the payment, including the terms of any oral agreement or understanding pursuant to which it was made.
(1)			[Continuation button]
(2)			[Continuation button]
(3)			[Continuation button]

[Continuation button]

PART B – Persuader Payments to Employees and Employee Committees. Complete Part B if you made, directly or indirectly, any payment (including reimbursed expenses) to any of your employees, or to any group or committee of your employees, for the purpose of causing them to persuade other employees to exercise or not to exercise, or as to the manner of exercising, the right to organize and bargain collectively through representatives of their own choosing unless such payments were contemporaneously or previously disclosed to other employees.
10. Name of Recipient Type of Recipient:  Employee  Employee Group/Committee If you checked “Employee Group/Committee” provide contact name and title: Street ______________________________________________ City____________________________ State _______ ZIP Code __________________ Telephone _________________________________ Email Address If the address of the group or organization differs from that of the individual recipient of the payment or the contact person for the group or organization, click here: [Continuation button]
11.a. Date of each payment. (mm/dd/yyyy)	11.b. Amount of each payment.	11.c. Kind of payment. (Specify if payment or loan, and if in cash or property.)	11.d. Explain fully the circumstances of the payment, including the terms of any oral agreement or understanding pursuant to which it was made.
(1)			[Continuation button]
(2)			[Continuation button]
(3)			[Continuation button]

[Continuation button]

Form LM-10 (XXXX) Page 2 of 4

PART C – Persuader Agreements/Arrangements with Labor Relations Consultants. Check the box(es) below and complete Part C if you made any agreement or arrangement with a labor relations consultant or other independent contractor or organization pursuant to which such person or organization undertook activities where an object thereof, directly or indirectly, was to:  Persuade employees to exercise or not to exercise, or as to the manner of exercising, the right to organize and bargain collectively through representatives of their own choosing.  Furnish you with information concerning activities of employees or of a labor organization in connection with a labor dispute in which you were involved.
12. Name of person with whom (or through) a separate agreement was made Organization ______________________________________________________ Position in Organization Street _____________________________________________________ City ____________________________ State _______ ZIP Code ____________ Telephone _________________________________ Email Address Employer Identification Number (EIN) ______________________________________________________________________________________________ If the address of the consultant or other organization differs from that of the individual with whom the separate agreement was made, click here: [Continuation button]
13.a. Date of the agreement or arrangement. (mm/dd/yyyy)	13.b. Terms and conditions. (Explain in detail; see instructions. Written agreements must be attached.) [Continuation button]
14. Information regarding activities performed or to be performed by the labor relations consultant pursuant to agreement or arrangement.
14.a. Nature of activities performed or to be performed by the labor relations consultant pursuant to agreement or arrangement:
PERSUADER ACTIVITIES: Select each activity performed or to be performed, if the object thereof was, directly or indirectly, to persuade employees concerning their rights to organize or bargain collectively through representatives of their own choosing, or their right to engage in any protected concerted activity in the workplace:  Drafting, revising, or providing written materials for presentation, dissemination, or distribution to employees  Drafting, revising, or providing a speech for presentation to employees  Drafting, revising, or providing audiovisual or multi-media presentations for presentation, dissemination, or distribution to employees  Drafting, revising, or providing website content for employees  Planning or conducting individual or group employee meetings		 Developing or administering employee attitude surveys concerning union awareness, sympathy, or proneness  Training supervisors or employer representatives to conduct individual or group employee meetings  Coordinating or directing the activities of supervisors or employer representatives  Establishing or facilitating employee committees  Developing personnel policies or practices  Deciding which employees to target for persuader activity or disciplinary action  Conducting a seminar for supervisors or employer representatives  Other		INFORMATION SUPPLYING ACTIVITIES: Select each activity whereby the labor relations consultant supplies you with information concerning the activities of employees or a labor organization in connection with a labor dispute in which you are involved:  Supplying information obtained from:  Research or investigation concerning employees or labor organizations  Supervisors or employer representatives  Employees, employee representatives, or union meetings  Surveillance of employees or union representatives (video, audio, Internet, or in person) Other [Continuation button]
14.b. Period during which performed.			14.c. Extent performed.
14.d. Name of person(s) who performed activities Type of Person:  Employee of Consultant  Independent Contractor  Separate Organization Organization ______________________________________________________ Position in Organization ­­­­­­­­­­­­­­­­­­­­­­______________________________________ Street ______________________________________________ City____________________________ State _______ ZIP Code __________________ Telephone _________________________________ Email Address If the address of the organization differs from the business address of the person who performed the activities, or if more than one person performed the activities, click here: [Continuation button]

[Continuation button]

Form LM-10 (XXXX) Page 3 of 4

PART C – Persuader Agreements/Arrangements with Labor Relations Consultants. Continued
14.e. Identify subject employees. [Continuation button]			14.f. Identify subject labor organizations. [Continuation button]
15.a. Date of each payment. (mm/dd/yyyy)	15.b. Amount of each payment.	15.c. Kind of payment. (Specify if payment or loan, and if in cash or property.)		15.d. Explain fully the circumstances of the payment(s), including the terms of any oral agreement or understanding pursuant to which it was made.
(1)				[Continuation button]
(2)				[Continuation button]
(3)				[Continuation button]

[Continuation button]

PART D – Expenditures Made to Interfere With, Restrain, or Coerce Employees; Obtain Information Concerning Employees or a Labor Organization. Check the box(es) below and complete Part D if you made:  Any expenditure where an object thereof, directly or indirectly, was to interfere with, restrain, or coerce employees in the right to organize and bargain collectively through representatives of their own choosing; or  Any expenditure where an object thereof, directly or indirectly, was to obtain information concerning the activities of employees or of a labor organization in connection with a labor dispute in which you were involved.
16. Name of Recipient Type of Recipient:  Employee  Independent Contractor  Business/Organization If you checked “Business/Organization,” provide contact name and title: Street ______________________________________________ City____________________________ State _______ ZIP Code __________________ Telephone _________________________________ Email Address If the address of the consultant or other organization differs from that of the individual with whom the separate agreement was made, click here: [Continuation button]
17.a. Date of each expenditure. (mm/dd/yyyy)	17.b. Amount of each expenditure.	17.c. Kind of expenditure (Specify if payment or loan, and if in cash or property.)	17.d. Explain fully the circumstances of the expenditure(s), including the terms of any oral agreement or understanding pursuant to which they were made.
(1)			[Continuation button]
(2)			[Continuation button]
(3)			[Continuation button]

[Continuation button]

Form LM-10 (XXXX) Page 4 of 4