LM-21 Form 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. 1215-0188
Expires 09-30-2011

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

For Official Use Only
READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT

E
2. Period Covered
By This Report
From:

1 . File Number C-

Month/Day/Year
( mm/dd/yyyy )

Month/Day/Year
( mm/dd/yyyy )

Through:

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

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

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

Street

Street

City

City
State

ZIP Code + 4

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).
President
(if other title, see
instructions)

17. Signed
Title

President

18. Signed
Title

Treasurer
(If other title, see
instructions)

Treasurer

On

On
Date

Telephone Number

Date

Telephone Number

Print Report

Form LM-21 (2003)

Page 1 of 2

File Number C-

Name of Person Filing:

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

Employer
Trade Name

Street

Attention To

City

Title

State

5.b. Termination Date

ZIP Code + 4

5.c. Amount

6. TOTAL RECEIPTS FROM ALL EMPLOYERS

Additional Employer Addresses
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)

Additional Officers & Employees
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:

15.b. Trade Name, If any:

15.c. To Whom Paid

15.d. Amount

Name

15.e. Purpose

Title
Organization

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

Street
City
State Washington

ZIP Code + 4

16. TOTAL DISBURSEMENTS FOR ALL REPORTABLE ACTIVITY

Form LM-21 (2003)

Additional Reportable Activities

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