LM-10 Form LM-10 Employer Report

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

FORM LM-10
EMPLOYER REPORT

Form approved
Office of Management
and Budget
No. 1245-0003
Expires 10-31-2013

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

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT
Part A

E

3. Name and address of Reporting Employer (inc. trade name, if any).

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

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

2. Fiscal Year
Covered
From:

1. File Number E-

/

/

Through:

/

/

4. Name and address of President or corresponding principal officer, if
different from address in Item 3.

Employer

Name

Trade Name
Attention To

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

Title
Mailing Address

Street

P.O. Box, Bldg., Room No., if any

City

Street

State

ZIP Code + 4

City
State

ZIP Code + 4

5. Any other address where records necessary to verify this report will be
available for examination.

6. Indicate by checking the appropriate box or boxes where records
necessary to verify this report will be available for examination.

Name

Address in Item 3

Title

Address in Item 4

Organization

Address in Item 5

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

Street
City
State

ZIP Code + 4

7. Type of organization.
Partnership

Corporation

Individual

Other (specify)

Signatures
Each of the undersigned, duly authorized officers of the above employer 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 VIII on penalties in the instructions.)

President
(if other title, see
instructions)

13. Signed
Title President

On

/

/
Date

Form LM-10 - Part A (2003)

14. Signed
Title

On
Telephone Number

Treasurer

/

/
Date

Print Report

Treasurer
(if other title, see
instructions)

Telephone Number

Page 1 of 3

Part A, Continued
Name of Reporting Employer:

File Number E-

8. Type of Reportable Activity Engaged In By Employer
Read the following questions and the accompanying instructions carefully, taking into consideration the exclusions listed in
the instructions for these items, and check either ''Yes" or ''No'' for each item. For each item that is answered ''Yes'', you must
attach a Part B which appears on Page 3. Complete a separate Part B for each ''Yes'' answer to any of Items 8.a. through 8.f.
Also, if the answer is ''Yes'' for more than one person or organization, complete a separate Part B for each person or
organization. If you answer ''Yes'', enter the number of Part Bs that are submitted for that item in the line indicated.

If ''Yes", number
of Part Bs
attached

DURING THE FISCAL YEAR COVERED BY THIS REPORT:
YES

NO

YES

NO

8.a. Did you make or promise or agree to make, directly or indirectly, any payment or loan of
money or other thing of value (including reimbursed expenses) to any labor organization or
to any officer, agent, shop steward, or other representative or employee of any labor
organization?
8.b. Did you make, directly or indirectly, any payment (including reimbursed expenses) to any
of your employees, or to any group or committee of your employees, for the purpose of
causing them to persuade other employees to exercise or not to exercise, or as to the
manner of exercising, the right to organize and bargain collectively through representatives
of their own choosing without previously or at the same time disclosing such payment to all
such other employees?
8.c. Did you make any expenditure where an object thereof, directly or indirectly, was to
interfere with, restrain, or coerce employees in the right to organize and bargain collectively
through representatives of their own choosing?

YES

NO

8.d. Did you make any expenditure where an object thereof, directly or indirectly, was to obtain
information concerning the activities of employees or of a labor organization in connection
with a labor dispute in which you were involved?

YES

NO

8.e. Did you make any agreement or arrangement with a labor relations consultant or other
independent contractor or organization pursuant to which such person undertook activities
where an object thereof, directly or indirectly, was to persuade employees to exercise or not
to exercise, or as to the manner of exercising, the right to organize and bargain collectively
through representatives of their own choosing; or did you make any payment (including
reimbursed expenses) pursuant to such an agreement or arrangement?

YES

NO

8.f. Did you make any agreement or arrangement with a labor relations consultant or other
independent contractor or organization pursuant to which such person undertook activities
where an object thereof, directly or indirectly, was to furnish you with information concerning
activities of employees or of a labor organization in connection with a labor dispute in which
you were involved; or did you make any payment pursuant to such agreement or
arrangement?

YES

NO

TOTAL NUMBER OF PART Bs FOR THIS REPORT IS

Form LM-10 - Part A (2003), Continued

New LM-10 Part B

0

Page 2 of 3

Part B
Name of Reporting Employer:

Check Item Number (from Page 2)
to which this Part B applies

9.a.

Agreement

File Number E-

ITEM 8.a

Payment

ITEM 8.b

ITEM 8.c

ITEM 8.d

ITEM 8.e

9.c. Position In labor organization or with employer (if an independent
labor consultant, so state).

Both

9.b. Name and address of person with whom or through whom a
separate agreement was made or to whom payments were
made.

9.d. Name and address of firm or labor organization with whom
employed or affiliated.

Name

Organization

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

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

Street

Street

City

City

State

ITEM 8.f

State

ZIP Code + 4

10.a. Date of the promise, agreement, or arrangement pursuant to
which payments or expenditures were agreed to or made.

ZIP Code + 4

10.b. The promise, agreement, or arrangement was:
Oral

Written*

Both

(*Written agreements entered into during the fiscal year must be attached.)

11.a. Date of each payment or
expenditure ( mm/dd/yyyy ).

11.b. Amount of each payment
or expenditure

11.c. Kind of each payment or expenditure (Specify whether
payment or loan, and whether in cash or property)

Continuation page for Item 11

12. Explain fully the circumstances of all payments, including the terms of any oral agreement or understanding pursuant to which they were made.

Form LM-10 - Part B (2003)

Add More Item 12 Information

Page 3 of 3