Form LM-30 Labor Organization Officer and Employee Report

For Official Use Only

Employee

State

ZIP

Form Approved
Office of Management and Budget
No. 1245-0003
Expires 08-31-2016

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

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

Page 1 of 2

Signed ______________________________________________________

30 - 1

Date (mm/dd/yyyy)

On ______________________

Form LM-30 (Revised 2011)

Telephone Number ______________________________

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.

15. Signature and Verification

City ____________________________________ State ___________ ZIP ______________________

Street address _____________________________________________________________________

Contact name ___________________________________________ Telephone __________________

6. Name of represented employer _______________________________________________________

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

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.

Email address (optional)

Your officer position or job title

City

ZIP

Officer

Street address
State

File number

City

Street address

Name (first, middle, last)

4. Your Contact Information

(mm/dd/yyyy)

through _______________

Name

5. Labor Organization Identifying Information

PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.

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

(mm/dd/yyyy)

2. Fiscal Year Covered: from _______________

1. LM-30 File Number: U- _______________

E

FORM 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.

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

a. Labor Organization

b. Trust

c. Employer

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

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

11.b. Value of dealings

11.a. Nature of dealings

Page 2 of 2

13.b. Type of entity:

Is the entity

an employer or

a consultant?

City ____________________________________ State ________ ZIP ___________________

Mailing address _______________________________________________________________

Contact name ______________________________________Telephone __________________

Name of employer or labor relations consultant ______________________________________

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

30 - 2

14.b. Amount or value of payment

14.a. Nature of payment

Form LM-30 (Revised 2011)

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.

City ____________________________________ State ________ ZIP ___________________

Street address ______________________________________________________________

Contact name ______________________________________Telephone _________________

___________________________________________________________________________

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

9. Business deals with

City ____________________________________ State ________ ZIP ___________________

Street address ______________________________________________________________

Contact name ______________________________________Telephone __________________

8. Name of business ___________________________________________________________

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.

File Number U - ____________________