# FORM LM

- 4 LABOR ORGANIZATION ANNUAL 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.

READ THE INSTRUCTIONS CAREFULLY BE FORE PREPARING THIS REPORT.

For Official Use Only 1. FILE NUMBER 2. PERIOD COVERED 3. (a) AMENDED

— If this is an amended report, check here:

MO DAY YEAR

— From (b) HARD SHIP

— If filing under hardship procedures check here:

Through (c) TERMINAL

— If this is a terminal report, check here:

8. MAILING ADDRESS ( Type or print in capital letters.)

First Name

IMPORTANT

Peel off the address label from the back of the package Last Name

and place it here.

If the label information is correct, leave Items 4 thro ugh 8 blank

. P.O. Box

 Building and Room Number (if any)

If any of the label information is incorrect, complete Items 4 through 8.

Number and Street

4. A FFILIATION OR ORGANIZATION NAME City

5. DESIGNATION ( Local, Lodge, etc.) 6. DESIGNATION NUMBER

State ZIP Code + 4

7. UNIT NAME (if any)

19. ADDITIONAL INFORMATION

Item Number

Each of the undersigned, duly authorized officers of the above labor organization, declares, under penalty of perj ury 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 VI on penalties in the instructions.)

20. SIGNED: ________________________________________________________ PRESIDENT 21. SIGNED: ____________________________________________________

__ TREASURER

(If other title, (If other title,

/ / ( )

-- see instructions.) / / ( )

-- see instructions.)

Date T elephone Number Date Telephone Number

Form LM

- 4 (Revised XXXX ) 4

- 1 Page 1 of 2 U.S. Department of Labor

Office of La bor

- Management Standards

Washington, DC 20210 Form Approved

Office of Management and Budget

No. 1245

- 0003

Expires XX

- XX

- XXXX FOR USE ONLY BY LABOR ORGANIZATIONS WITH LESS THAN $10,000 IN TOTAL ANNUAL RECEIPTSFILE NUMBER :

—



### Complete Items 9 through 18.

9. During the r eporting period, did your organization

have any changes in its constitution and bylaws

(other than rates of dues and fees) or in practices/ Yes No



### procedures listed in the instruction s ?

.......................... (If the constitution and bylaws have chang ed,

attach two new dated copies. If practices/

procedures have changed, see the instructions.)

10. Did your organization change its rates of dues Yes No



### and fees during the reporting period?

.......................... (If “Yes,” report the new rates in Item 19

on page 1.)

11. Did your organization discover any loss or

shortage of funds or property during the Yes No



### reporting period?

................................ ........................... (If “Yes,” provide details in Item 19 on page 1.

Answer “Yes” even if there has been repayment

or recovery.)

12. Was your organization insured by a Yes No



### fidelity bond during the reporting period?

.....................

If “Yes,” enter the maximum amount

r ecoverable under the bond for los s

c aused by any person. $

13. How many members did your

organization have at the end of the

reporting period? 14. Enter the total value of your organization’s

assets at the end of the r eporting period

(cash, bank accounts, equipment, etc.) $

15. Enter the total liabilities (debts) of your

organization at the end of the reporting

period (unpaid bills, loans owed, etc.) $

16. Enter the total receipts of your organization

durin g the reporting period (dues, fees,

interest received, etc.). (If $10,000 or more,

your organization must file Form LM

- 2 or

LM

- 3 instead of this form.) $

17. Enter the total disbursements made by your

organization during the reporting period (per

capita tax, loans made, net payment to

officers, payments for office supplies, etc.). $

18. Enter the total payments to officers and

employees during the reporting period

(gross salaries, lost time payments,

allowances, expenses, etc.). $

Please be sure to:

• Enter your union’s 6

- digit file number in Item 1.

• Report a time period of no more than one year in Item 2.

• Have your union’s president and treasurer sign the Form LM

- 4

in Items 20 and 21.

• 

### FILE ON TIME. Form LM

- 4 must be filed wi thin 90 days after

the end of your union’s fiscal year.

Form LM

- 4 (Revised XXXX ) 4

- 2 Page 2 of 2

Enter Amounts in Dollars Only

— Do Not Enter Cents