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 BY LABOR ORGANIZATIONS WITH LESS THAN $10,000 IN TOTAL ANNUAL RECEIPTS

Form Approved
Office of Management and Budget
No. 1215-0188
Expires 9-30-2011

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.

1. FILE NUMBER

For Official Use Only

2. PERIOD COVERED
DAY
MO

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

YEAR

From
(b) TERMINAL — If your organization ceased to exist and this is its
terminal report, see Section X of the instructions and check here:

Through

8. MAILING ADDRESS (Type or print in capital letters)
First Name

IMPORTANT
Peel off the address label from the back of the package

Last Name

and place it here.
If the label information is correct, leave Items 4 through 8 blank.

P.O. Box Building and Room Number (if any)

If any of the label information is incorrect, complete Items 4
through 8.
Number and Street
4. AFFILIATION OR ORGANIZATION NAME
City
5. DESIGNATION (Local, Lodge, etc.)

6. DESIGNATION NUMBER
State

7. UNIT NAME (if any)

ZIP Code + 4

19. ADDITIONAL INFORMATION (If more space is needed, attach additional pages properly identified.)
Item Number

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:

PRESIDENT

/

/
Date

Form LM-4 (Revised 2000)

(

)

—

21. SIGNED:

(If other title,
see instructions.)

TREASURER

/

/
Date

Telephone Number
4-1

(

)

—

(If other title,
see instructions.)

Telephone Number
Page 1 of 2

Enter Amounts in Dollars Only — Do Not Enter Cents

FILE NUMBER:

14. Enter the total value of your organization’s
assets at the end of the reporting period
(cash, bank accounts, equipment, etc.)

Complete Items 9 through 18.
9.

During the reporting period, did your
organization have any changes in its constitution and bylaws (other than rates of
dues and fees) or in practices/procedures
listed in the instructions?

Yes

15. Enter the total liabilities (debts) of your
organization at the end of the reporting
period (unpaid bills, loans owed, etc.)

No

(If the constitution and bylaws have
changed, attach two new dated copies.
If practices/procedures have changed,
see the instructions.)
Yes

,

17. Enter the total disbursements made by
your organization during the reporting
period (per capita tax, loans made, net
payment to officers, payments for office
supplies, etc.).

11. Did your organization discover any loss or
shortage of funds or property during the
reporting period?

Yes

$

,

$

,

$

,

No

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

(If “Yes,” provide details in Item 19 on page
1. Answer “Yes” even if there has been
repayment or recovery.)

Please be sure to:
Yes

No

12. Was your organization insured by a fidelity
bond during the reporting period?

Form LM-4 (Revised 2000)

$

No

(If “Yes,” report the new rates in Item 19
on page 1.)

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

,

16. Enter the total receipts of your organization
during 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.)

10. Did your organization change its rates of
dues and fees during the reporting period?

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

$

$

,

•

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.

,
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