(2011) Form-30 Labor Organization Officer and Employee Report

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

FORM LM-30
LABOR ORGANIZATION OFFICER AND EMPLOYEE REPORT

Form Approved
Office of Management and Budget
No. 1245-0005
Expires 09-30-2014

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 BEFORE PREPARING THIS REPORT.

E
5. Labor Organization Identifying Information
Name

1. LM-30 File Number: U- _______________
2. Fiscal Year Covered: from _______________

through _______________

(mm/dd/yyyy)

Street address

(mm/dd/yyyy)

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

City

State

ZIP

4. Your Contact Information
Name (first, middle, last)

File number

Street address

Officer

City

State

ZIP

Employee

Your officer position or job title

Email address (optional)

f 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 _______________________________________________________

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

Contact name ___________________________________________ Telephone __________________

Street address _____________________________________________________________________

City ____________________________________ State ___________ ZIP ______________________

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

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)

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Form LM-30 (Revised 2011)

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 an 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 ___________________________________________________________

11.a. Nature of dealings

Contact name ______________________________________Telephone __________________

Street address ______________________________________________________________

City ____________________________________ State ________ ZIP ___________________

9. Business deals with

a. Labor Organization

b. Trust

c. Employer

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

11.b. Value of dealings
12.a. Nature of interest, benefit, arrangement, or income

___________________________________________________________________________
Contact name ______________________________________Telephone _________________
Street address ______________________________________________________________
City ____________________________________ State ________ ZIP ___________________
12.b. Amount or value of interest, benefit, arrangement, or income

PART C – OTHER EMPLOYER OR LABOR RELATIONS CONSULTANT. An employer (other than an 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 employer listed in Part A.
13.a. Contact information for employer or labor relations consultant

14.a. Nature of payment

Name of employer or labor relations consultant ______________________________________
Contact name ______________________________________Telephone __________________
Mailing address _______________________________________________________________
City ____________________________________ State ________ ZIP ___________________
13.b. Type of entity:

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Is the entity

an employer or

a consultant?

14.b. Amount or value of payment

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Form LM-30 (Revised 2011)