LM-4 Form Facsimile

FORM LM-4 LABOR ORGANIZATION ANNUAL REPORT
FOR USE ONLY BY LABOR ORGANIZATIONS WITH LESS THAN $10,000 IN TOTAL ANNUAL RECEIPTS

Form Approved
Office of Management and Budget
No. 1245-0003
Expires 09-30-2021

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

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.

1. FILE NUMBER

For Official Use Only

2. PERIOD COVERED
MO
DAY

3. (a) AMENDED — If this is an amended report, check here:
YEAR

From

(b) HARDSHIP — If filing under hardship procedures check here:

Through

(c) TERMINAL — If this is a terminal report, check here:

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READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.

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

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First Name

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IMPORTANT
Last Name

If the label information is correct, leave Items 4 through 8 blank.

P.O. Box  Building and Room Number (if any)

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Peel off the address label from the back of the package
and place it here.

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

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Number and Street

5. DESIGNATION (Local, Lodge, etc.)

City

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4. AFFILIATION OR ORGANIZATION NAME
6. DESIGNATION NUMBER

ZIP Code + 4

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State

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7. UNIT NAME (if any)

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19. ADDITIONAL INFORMATION
Item Number

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 Section VI on penalties in the instructions.)

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20. SIGNED: ________________________________________________________ PRESIDENT
(If other title,
/
/
(
)
-see instructions.)
Date
Telephone Number
Form LM-4 (Revised 2016)

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21. SIGNED: ______________________________________________________ TREASURER
(If other title,
/
/
(
)
-see instructions.)
Date
Telephone Number
Page 1 of 2

Enter Amounts in Dollars Only — Do Not Enter Cents

15.

Yes

No

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No

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Yes

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12. Was your organization insured by a
fidelity bond during the reporting period? .....................

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If “Yes,” enter the maximum amount
recoverable under the bond for loss
caused by any person.

Yes

18.

No

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Enter the total receipts of your organization
during 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.)

$

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.).

$

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.

13. How many members did your
organization have at the end of the
reporting period?

Form LM-4 (Revised 2016)

$

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16.

17.

11. Did your organization discover any loss or
shortage of funds or property during the
reporting period? ...........................................................
(If “Yes,” provide details in Item 19 on page 1.
Answer “Yes” even if there has been repayment
or recovery.)

Enter the total liabilities (debts) of your
organization at the end of the reporting
period (unpaid bills, loans owed, etc.)

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No

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10. Did your organization change its rates of dues
and fees during the reporting period? ..........................
(If “Yes,” report the new rates in Item 19
on page 1.)

Yes

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9. During the reporting period, did your organization
have any changes in its constitution and bylaws
(other than rates of dues and fees) or in practices/
procedures listed in the instructions? ..........................
(If the constitution and bylaws have changed,
attach two new dated copies. If practices/
procedures have changed, see the instructions.)

Enter the total value of your organization’s
assets at the end of the reporting period
(cash, bank accounts, equipment, etc.)

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14.

Complete Items 9 through 18.

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FILE NUMBER:

 FILE ON TIME. Form LM-4 must be filed within 90 days after
the end of your union’s fiscal year.

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