Form LM-20 Agreement and Activities Report

L M-20 – AGREEMENT

& ACTIVITIES REPORT

OMB No. 1245-0003. Expires XX-XX-XXXX.

IMPORTANT: 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 Reporting and Disclosure Act of 1959, as amended (LMRDA).

O ffice of Labor-Management Standards

U.S. Department of Labor

For Official Use Only

E

 Read the instructions carefully before completing this report. 

1.a. File Number: C-	1.b.  Hardship Exemption		1.c.  Amended Report
2. Contact information for person filing: Organization Street City __________________________________________ State _____ ZIP Code ______ Email Address _____________________________ Employer Identification Number (EIN) __________________________ Contact Name Title		3. Other address where records necessary to verify this report are kept: Name Title Organization Street City State ZIP Code Email Address ____________________________________________
4. Fiscal Year Covered: from ______________through ______________ (mm/dd/yyyy) (mm/dd/yyyy)		5. Type of person a.  Individual b.  Partnership c.  Corporation d.  Other
6. Full name and address of employer with whom agreement or arrangement was made:  Check this box if you are filing a report for a union avoidance seminar. Organization (including trade name, if any) Street City __________________________________________ State _____ ZIP Code ______ Email Address _____________________________ Employer Identification Number (EIN) __________________________ Contact Name Title		7. Date agreement or arrangement entered into:_____________________ mm/dd/yyyy
		8. Person(s) through whom agreement or arrangement made: Employer Representative: Name and Title OR (b) Prime Consultant: Name and Title Employer Identification Number (EIN) __________________________ Address _________________________________________________

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 Section VII on penalties in the instructions.)
13. Signed President (If other title, see instructions.)	14. Signed Treasurer (If other title, see instructions.)
On Date (mm/dd/yyyy) Telephone Number	On Date (mm/dd/yyyy) Telephone Number

Form LM-20 (2016) Page 1 of 2

Name of person filing:

File Number: C-

9. Check the appropriate box(es) to indicate whether an object of the activities undertaken is directly or indirectly:

a.  To persuade employees to exercise or not to exercise, or persuade employees as to the manner of exercising, the right to organize and bargain collectively through representatives of their own choosing.

b.  To supply an employer with information concerning the activities of employees or a labor organization in connection with a labor dispute involving such employer, except information for use solely in conjunction with an administrative or arbitral proceeding or a criminal or civil judicial proceeding.

10. Terms and conditions. (Explain in detail; see instructions. Written agreements must be attached by clicking the “Add Attachments” link at the top of the form. If reporting a union avoidance seminar, a single copy of the registration form and a description of the seminar provided to attendees also must be attached by clicking the “Add Attachments” link at the top of the form.)

11. Information regarding activities performed or to be performed by the labor relations consultant pursuant to agreement or arrangement. (See instructions.)
a. Nature of activities performed or to be performed by the labor relations consultant pursuant to the agreement or arrangement:
PERSUADER ACTIVITIES: Select from the following reportable activities those which, per agreement with the employer(s) named in item 6, have been or will be performed:  Drafting, revising, or providing written materials for presentation, dissemination, or distribution to employees  Drafting, revising, or providing a speech for presentation to employees  Drafting, revising, or providing audiovisual or multi-media presentations for presentation, dissemination, or distribution to employees  Drafting, revising, or providing website content for employees  Planning or conducting individual employee meetings  Planning or conducting group employee meetings ADDITIONAL INFORMATION:	 Training supervisors or employer representatives to conduct individual or group employee meetings  Coordinating or directing the activities of supervisors or employer representatives  Establishing or facilitating employee committees  Developing employer personnel policies or practices  Identifying employees for disciplinary action, reward, or other targeting  Conducting a seminar for supervisors or employer representatives  Speaking with or otherwise communicating directly with employees.  Other		INFORMATION-SUPPLYING ACTIVITIES: Select each activity whereby you supply an employer with information concerning the activities of employees or a labor organization in connection with a labor dispute Involving such employer:  Supplying information obtained from:  Research or investigation concerning employees or labor organizations  Supervisors or employer representatives  Employees, employee representatives, or union meetings  Surveillance of employees or union representatives (electronically or in person) Other
11.b. Period during which activities performed: _______________________ mm/dd/yyyy – mm/dd/yyyy		11.c. Extent of performance:
11.d. Name and address of person(s) through whom activities were performed or will be performed: Name and Title Type of Person:  Employee of Consultant  Independent Contractor Organization Street City ____________________State ______ ZIP Code Email Address Employer Identification Number (EIN) __________________________		12.a. Identify subject groups of employees:
		12.b. Identify subject labor organizations:

Form LM-20 (2016) Page 2 of 2