LM-21 Receipts and Disbursements Report

U.S. Department of Labor Office of Labor-Management

Standards

Washington, DC 20210

FORM LM-21

RECEIPTS AND DISBURSEMENTS REPORT

Form approved Office of Management

and Budget No. 1245-0003

Expires 08/31/2026

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

E

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT

1. File Number C-	2. Period Covered by This Report From:	Month/Day/Year (mm/dd/yyyy)	Through:	Month/Day/Year (mm/dd/yyyy)
		/ /		/ /

A. Person Filing
3. Name and mailing address (include ZIP Code):	4. Any other address where records necessary to verify this report are kept:
Name _	Name
Title _	Title
Organization ____________­____________________________________	Organization
Employer Identification Number __________________________________	P.O. Box, Building and Room Number, if any________________________
P.O. Box, Building and Room Number, if any__________________________ Street City State ZIP Code + 4	Street City State ZIP Code + 4

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 the Section on penalties in the instructions)
17. Signed Title President	President (If other title, see instructions)	18. Signed Title Treasurer	Treasurer (If other title, see instructions)
On Date Telephone Number		On Date Telephone Number

Name of Person Filing:

File Number C-

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: Employer P.O. Box, Bldg., Room No., if any Employer Identification Number _____________________________ Street Trade Name City Attention To: State ______________________ZIP Code + 4 Title
5.b. Termination Date	5.c. Amount
6. TOTAL RECEIPTS FROM ALL EMPLOYERS

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: (a) Name (b) Salary (c) Expenses (d) Totals
				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)

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.a. Employer Name and Employer Identification Number:	15.b. Trade Name, if any:
15.c. To Whom Paid Name Title Organization Employer Identification Number _______________________________ P.O. Box, Building and Room Number, if any ______________________ Street City State ZIP Code + 4	15.d. Amount
	15.e. Purpose
16. TOTAL DISBURSEMENTS FOR ALL REPORTABLE ACTIVITY

Form LM-21 (XXXX)

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