LM-30 Labor Organization Officer and Employees Report

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

FORM LM-30 LABOR ORGANIZATION
OFFICER AND EMPLOYEE ANNUAL 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.
For Official Use Only

PLEASE READ THE INSTRUCTIONS CAREFULLY, ESPECIALLY PART IX (PAGES 14 - 18), BEFORE PREPARING
THIS REPORT. YOU ARE NOT REQUIRED TO FILE THIS REPORT UNLESS YOU, YOUR SPOUSE, OR MINOR
CHILD HAVE RECEIVED A PAYMENT, ENGAGED IN ANY TRANSACTIONS OR ARRANGEMENTS OR HELD AN
INTEREST OF THE TYPES DESCRIBED IN PART II OF THE INSTRUCTIONS (PAGES 1 - 9).

E
2. PERIOD COVERED:

PART A

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

1. LM-30 FILE NUMBER: U - ___________
FROM

/

/

Add Item 4 Page
4. LABOR ORGANIZATION IDENTIFYING INFORMATION:

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

THROUGH

/

/

A. NAME

B. MAILING ADDRESS (LINE 1)

3. CONTACT INFORMATION OF REPORTING PERSON:
A. FIRST NAME

C. LAST NAME

B. MIDDLE NAME

C. MAILING ADDRESS (LINE 2)

D. MAILING ADDRESS (LINE 1)

D. CITY

E. MAILING ADDRESS (LINE 2)

E. FILE NUMBER

F. CITY

G. STATE

H. ZIP CODE

STATE

F. OFFICER

ZIP CODE

EMPLOYEE

G. YOUR OFFICER POSITION OR JOB TITLE
I. EMAIL ADDRESS (optional)
H. DID YOU HOLD THIS POSITION OR JOB TITLE AT THE END OF
THE REPORTING PERIOD?
YES

NO

5. SUMMARY (FROM ATTACHED PART B)
A. TOTAL REPORTED INCOME OR OTHER PAYMENTS (total from Schedule 2, Item F, Column (1) of each Part B)

$

0

B. TOTAL REPORTED ASSETS (total from Schedule 2, Item F, Column (2) of each Part B)

$

0

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.
8. SIGNED

ON

/

/

Date (mm/dd/yyyy)

Validate

Telephone Number

Calculate

Page 1 of 9

Form LM-30 (Revised 2007)

LM-30 File Number U - _____________

EMPLOYER or BUSINESS RELATIONSHIPS
6. EMPLOYER RELATIONSHIPS
Generally, you must complete Schedules 1, 2, and 3 of Part B, as fully explained in the instructions, if you, your spouse, or minor child had an arrangement or engaged in a transaction
with, or held an interest in, or received income or other payment from (including any reimbursed expenses), or made loans to or received loans from, an employer or a labor relations
consultant to an employer that meets any of the following conditions:
An employer whose employees your labor organization represents or is actively seeking to represent; or
An employer in competition with an employer whose employees your labor organization represents or is actively seeking to represent; or
An employer that is a trust in which your labor organization is interested as defined in section 3(l) of the LMRDA; or
An employer that is a non-profit organization that receives or is actively and directly soliciting (other than by mass mail, telephone bank, or mass media) money, donations or
contributions from your labor organization; or
An employer that is a labor organization that (1) has employees your union represents or is actively seeking to represent, (2) has employees in the same occupation as those
represented by your union; (3) claims jurisdiction over work that is also claimed by your union; (4) is a party to or will be affected by any proceeding in which you have voting
authority or other ability to influence the outcome of the proceeding; or (5) has made a payment to you for the purpose of influencing the outcome of an internal union election; or
An employer that has made a payment to you for any of the following purposes: (1) not to organize employees; (2) to influence employees in any way with respect to their
rights to organize; (3) to take any action with respect to the status of employees or others as members of a labor organization; (4) to take any action with respect to bargaining
or dealing with employers whose employees your organization represents or is actively seeking to represent; or (5) to influence the outcome of an internal union election; or
An employer whose interests are in actual or potential conflict with the interests of your labor organization or your duties to your labor organization.
Before proceeding, review Part II of the instructions (pages 1-9) to determine if any reporting exceptions apply to your situation. If the above conditions exist and none of the exceptions
apply, then you must complete a separate Part B for each employer or labor relations consultant to an employer.

a. DO YOU HAVE ANY OF THESE RELATIONSHIPS WITH EMPLOYERS OR LABOR RELATIONS CONSULTANTS?
b. If yes, record the number of employers and consultants: __________

YES

Add Employer Statement

NO
Add Labor Relations Statement

7. BUSINESS RELATIONSHIPS
Generally, you must complete Schedules 1, 2, and 4 of Part B, as fully explained in the instructions, if you, your spouse, or minor child had an arrangement or engaged in a transaction
with, or held an interest in, or received income or other payment from (including any reimbursed expenses), or made loans to or received loans from, a business, such as a goods vendor
or service provider, that meets any of the following conditions:
A substantial part of its business consists of buying or selling or otherwise dealing with an employer whose employees your labor organization represents or is actively seeking to
represent; or
Any part of its business consists of buying or selling or otherwise dealing with your labor organization; or
Any part of its business consists of buying or selling or otherwise dealing with a trust in which your labor organization is interested.
Before proceeding, review Part II of the instructions (pages 1-9) to determine if any reporting exceptions apply to your situation. If the above conditions exist and none of the exceptions
apply, then you must complete a separate Part B for each business.

a. DO YOU HAVE ANY OF THESE RELATIONSHIPS WITH A BUSINESS?

YES

NO

Add Business Statement

b. If yes, record the number of businesses: __________

If you answer "No" to both Item 6a and Item 7a, you are not required to file Form LM-30.
Calculate

Additional Information

Page 2 of 9

Form LM-30 (Revised 2007)