Form Lm-21 - Receipts And Disbursements Report

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FORM LM-21

U.S. Department of Labor

Form approved

Office of Labor-Management

Office of Management

Standards

and Budget

RECEIPTS AND DISBURSEMENTS REPORT

Washington, DC 20210

No. 1215-0188

Expires 12-31-2010

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 Relations and Disclosure Act of 1959, as amended. (LMRDA)

For Official Use Only

READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT

Month/Day/Year

2. Period Covered

1 . File Number C-

( mm/dd/yyyy )

By This Report

From:

Through:

A. Person Filing

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

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

Name

Title

Organization

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

Street

City

State

ZIP Code + 4

State

ZIP Code + 4

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 the Section on penalties in the instructions).

17. Signed

President

18. Signed

Treasurer

(If other title, see

(if other title, see

President

Treasurer

Title

instructions)

Date