Fillable Form Lm-1 - Labor Organization Information Report printable pdf download

Form Lm-1 - Labor Organization Information Report

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U.S. Department of Labor

Form approved

FORM LM-1

Office of Labor-Management

Office of Management

Standards

and Budget

LABOR ORGANIZATION INFORMATION REPORT

Washington, DC 20210

No. 1215-0188

Expires 09-30-2011

This report is mandatory under P.L. 86-257, as amended. Failure to comply may result in

For Official Use Only

criminal prosecution, fines, or civil penalties as provided by 29 U.S.C. 439 or 440.

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.

Identification Items (To be completed by all filers)

1. File Number

2. What is your organization's fiscal year ending date?

3. Is this the first Form LM-1 your organization has filed?

Yes, this is an INITIAL FORM LM-1.

No, this is an AMENDED FORM LM-1.

(Complete Items 1 through 9, 18, 20, and 21.)

(Complete Items 2 through 21.)

5. Designation (Local, Lodge, etc.)

4. Affiliation or Organization Name

6. Designation Number

7. Unit Name (if any)

Prefix

Number

Suffix

8. Mailing Address

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

Name

Title

Organization

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

Street

City

State

ZIP Code + 4

State

ZIP Code + 4

Signatures

Each of the undersigned, duly authorized officers of the above labor organization, 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.)

20. Signed

President

21. Signed

Secretary

(if other title, see

instructions)

President

Secretary

Date

Telephone Number

Date