LM-30 Labor Organization Officer and Employee Report

F

U.S. Department of Labor

Office of Labor-Management Standards

Washington, DC 20210

Form Approved

Office of Management and Budget

No. XXXX-XXXX

Expires XX-XX-XXXX

ORM LM-30

LABOR ORGANIZATION OFFICER AND EMPLOYEE REPORT

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.

PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.

For Official Use Only

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5. Labor Organization Identifying Information

Name

1. LM-30 File Number: U- _______________

2

Street address

. Fiscal Year Covered: from _______________ through _______________

(mm/dd/yyyy) (mm/dd/yyyy)

3

City State ZIP

. Amended Report – If this is an amended report, check here:

4. Your Contact Information

File number

Name (first, middle, last)

Officer Employee

Street address

Your officer position or job title

City State ZIP

E-mail address (optional)

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 Complete PART A, B, or C if, during the past fiscal year, you or your spouse or minor child directly or indirectly had a reportable interest in, transaction or arrangement with, or received income, payment, or benefit from the entities described below.

PART A – REPRESENTED EMPLOYER. An employer whose employees your labor organization represents or is actively seeking to represent.

6. Name of represented employer _______________________________________________________

Contact name ___________________________________________ Telephone __________________

Street address _____________________________________________________________________

City ____________________________________ State ___________ ZIP ______________________

7.a. Nature of interest, transaction, benefit, arrangement, income, or loan

7.b. Amount or value of interest, transaction, benefit, arrangement, income, or loan

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15. Signature and Verification

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.

Signed ______________________________________________________ On ______________________ Telephone Number ______________________________

Date (mm/dd/yyyy)

Page 1 of 2 30 - 1 Form LM-30 (Revised XXXX)

File Number U - ____________________

PART B – BUSINESS. A business, such as a vendor or service provider, (1) a substantial part of which consists of buying from, selling or leasing to, or otherwise dealing with the business of a Represented Employer described in Part A or (2) any part of which consists of buying from or selling or leasing directly or indirectly to, or otherwise dealing with your labor organization or with a trust in which your labor organization is interested.

8. Name of business ___________________________________________________________

Contact name ______________________________________Telephone __________________

Street address ______________________________________________________________

City ____________________________________ State ________ ZIP ___________________

11.a. Nature of dealings

9. Business deals with a. Labor Organization b. Trust c. Employer

11.b. Value of dealings

10. If 9.b. or 9.c. is checked give trust or employer’s name ____________________________

___________________________________________________________________________

Contact name ______________________________________Telephone _________________

Street address ______________________________________________________________

City ____________________________________ State ________ ZIP ___________________

12.a. Nature of interest, benefit, arrangement, or income

12.b. Amount or value of interest, benefit, arrangement, or income

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PART C – OTHER EMPLOYER OR LABOR RELATIONS CONSULTANT. An employer (other than a Represented Employer or Business covered under Parts A and B above) from whom a payment would create an actual or potential conflict between your personal financial interests and the interests of your labor organization (or your duties to your labor organization); or a labor relations consultant to such an employer or to the Represented Employer listed in Part A.

13.a. Contact information for employer or labor relations consultant

Name of employer or labor relations consultant ______________________________________

Contact name ______________________________________Telephone __________________

Mailing address _______________________________________________________________

City ____________________________________ State ________ ZIP ___________________

14.a. Nature of payment

13.b. Type of entity: Is the entity an employer or consultant?

14.b. Amount or value of payment

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Page 2 of 2 30 - 2 Form LM-30 (Revised XXXX)