LM-21 Receipts and Disbursements Report

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

FORM LM-21
RECEIPTS AND DISBURSEMENTS REPORT

Form approved
Office of Management
and Budget
No. 1245-0003
Expires XX-XX-XXXX

For Official Use Only

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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).

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT
E

2. Period Covered
By This Report
From:

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

/ /

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

Through:

/ /

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1. File Number C-

A. Person Filing

4. Any other address where records necessary to verify this report are kept:

Name ____________________________________________________

Name _____________________________________________________

Title _______________________________________________________

Title _______________________________________________________

Organization _______________________________________________

Organization ________________________________________________

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

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

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3. Name and mailing address (include ZIP Code):

___________________________________________________________________

Street ______________________________________________________________

Street ______________________________________________________________

City ________________________________________________________________

City ________________________________________________________________

State _____________________ ZIP Code + 4 _____________________________

State _____________________ ZIP Code + 4 _____________________________

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___________________________________________________________________

Signatures

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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 the Section on penalties in the instructions)

17. Signed ______________________________

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Title President

18. Signed _______________________________
Title Treasurer

Treasurer
(If other title,
see
instructions)

On ___________________ ______________________
Date
Telephone Number

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On ___________________ ______________________
Date
Telephone Number

President
(If other title, see
instructions)

Form LM-21 (2003)

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File Number C-

Name of Person Filing:

Report all receipts from employers in connection with labor relations advice or services regardless of the purposes of the advice
or services.

Employer

_____________________________________________

Mailing Address:

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5.a. Name and Address of Employer (including trade name, if any).

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

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B. Statement of Receipts

Trade Name ____________________________________________

Street

Attention To: ____________________________________________

City _____________________________________________________

Title ___________________________________________________

State _____________________ ZIP Code + 4 ___________________

5.b. Termination Date

__________________________________________________

5.c. Amount

C. Statement of Disbursements

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6. TOTAL RECEIPTS FROM ALL EMPLOYERS

Report all disbursements made by the reporting organization in connection with labor relations advice or services rendered
to the employers listed in Part B.

7. Disbursements to Officers and Employees:
(a) Name

(b) Salary (c) Expenses (d) Totals

9. Office and Administrative Expenses

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8. Total disbursements to officers and employees:

D. Schedule of Disbursements for Reportable Activity
15.a. Employer Name:

15.c. To Whom Paid

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10. Publicity

11. Fees for Professional Services
12. Loans Made
13. Other Disbursements
14. Total Disbursements (Sum of Items 8 – 13)

Use this Schedule to report only disbursements made for the purposes described in Part D of the
instructions.
15.b. Trade Name, if any:

15.d. Amount

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Name __________________________________________________
Title ____________________________________________________

15.e. Purpose

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Organization _____________________________________________

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

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Street ___________________________________________________

City ____________________________________________________
State _____________________ ZIP Code + 4 ___________________

16. TOTAL DISBURSEMENTS FOR ALL REPORTABLE ACTIVITY

Form LM-21 (2003)

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