U.S. Department of Labor Office of Labor-Management Standards Washington, DC 20210 FORM LM-10 EMPLOYER REPORT Form approved Office of Management and Budget No. 1215-0188 Expires 11-30-2006 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. For Official Use Only READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT Part A 3. Name and address of Reporting Employer (inc. trade name, if any). Month/Day/Year (mm/dd/yyyy) Month/Day/Year (mm/dd/yyyy) 2. Fiscal Year Covered From: 1. File Number E- / / / Through: / 4. Name and address of President or corresponding principal officer, if different from address in Item 3. Employer Name Trade Name Attention To P.O. Box, Building and Room Number, If any Title Mailing Address Street P.O. Box, Bldg., Room No., if any City Street State ZIP Code + 4 City State ZIP Code + 4 5. Any other address where records necessary to verify this report will be available for examination. 6. Indicate by checking the appropriate box or boxes where records necessary to verify this report will be available for examination. Name Address in Item 3 Title Address in Item 4 Organization Address in Item 5 P.O. Box, Building and Room Number, If any Street City State ZIP Code + 4 7. Type of organization. Partnership Corporation Individual Other (specify) Signatures Each of the undersigned, duly authorized officers of the above employer 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 VIII on penalties in the instructions.) President (if other title, see instructions) 13. Signed Title On / / Date 14. Signed Title On Telephone Number Treasurer (if other title, see instructions) / / Date Telephone Number Form LM-10 - Part A (2003) American LegalNet, Inc. www.USCourtForms.com Part A, Continued Name of Reporting Employer: File Number E- 8. Type of Reportable Activity Engaged In By Employer Read the following questions and the accompanying instructions carefully, taking into consideration the exclusions listed in the instructions for these items, and check either ''Yes" or ''No'' for each item. For each item that is answered ''Yes'', you must attach a Part B which appears on Page 3. Complete a separate Part B for each ''Yes'' answer to any of Items 8.a. through 8.f. Also, if the answer is ''Yes'' for more than one person or organization, complete a separate Part B for each person or organization. If you answer ''Yes'', enter the number of Part Bs that are submitted for that item in the line indicated. If ''Yes", number of Part Bs attached DURING THE FISCAL YEAR COVERED BY THIS REPORT: YES NO 8.b. Did you make, directly or indirectly, any payment (including reimbursed expenses) to any of your employees, or to any group or committee of your employees, for the purpose of causing them to persuade other employees to exercise or not to exercise, or as to the manner of exercising, the right to organize and bargain collectively through representatives of their own choosing without previously or at the same time disclosing such payment to all such other employees? YES NO 8.c. Did you make any expenditure where an object thereof, directly or indirectly, was to interfere with, restrain, or coerce employees in the right to organize and bargain collectively through representatives of their own choosing? YES NO 8.d. Did you make any expenditure where an object thereof, directly or indirectly, was to obtain information concerning the activities of employees or of a labor organization in connection with a labor dispute in which you were involved? YES NO 8.e. Did you make any agreement or arrangement with a labor relations consultant or other independent contractor or organization pursuant to which such person undertook activities where an object thereof, directly or indirectly, was to persuade employees to exercise or not to exercise, or as to the manner of exercising, the right to organize and bargain collectively through representatives of their own choosing; or did you make any payment (including reimbursed expenses) pursuant to such an agreement or arrangement? YES NO 8.f. Did you make any agreement or arrangement with a labor relations consultant or other independent contractor or organization pursuant to which such person undertook activities where an object thereof, directly or indirectly, was to furnish you with information concerning activities of employees or of a labor organization in connection with a labor dispute in which you were involved; or did you make any payment pursuant to such agreement or arrangement? YES NO 8.a. Did you make or promise or agree to make, directly or indirectly, any payment or loan of money or other thing of value (including reimbursed expenses) to any labor organization or to any officer, agent, shop steward, or other representative or employee of any labor organization? TOTAL NUMBER OF PART Bs FOR THIS REPORT IS Form LM-10 - Part A (2003), Continued American LegalNet, Inc. www.USCourtForms.com Part B Name of Reporting Employer: Check Item Number (from Page 2) to which this Part B applies 9.a. Agreement File Number E- ITEM 8.a Payment ITEM 8.b Both 9.b. Name and address of person with whom or through whom a separate agreement was made or to whom payments were made. ITEM 8.c ITEM 8.d ITEM 8.e ITEM 8.f 9.c. Position In labor organization or with employer (if an independent labor consultant, so state). 9.d. Name and address of firm or labor organization with whom employed or affiliated. Name Organization P.O. Box, Building and Room Number, if any P.O. Box, Building and Room Number, if any Street Street City City State ZIP Code + 4 10.a. Date of the promise, agreement, or arrangement pursuant to which payments or expenditures were agreed to or made. State ZIP Code + 4 10.b. The promise, agreement, or arrangement was: Oral Written* Both (*Written agreements entered into during the fiscal year must be attached.) 11.a. Date of each payment or expenditure ( mm/dd/yyyy ). 11.b. Amount of each payment or expenditure 11.c. Kind of each payment or expenditure (Specify whether payment or loan, and whether in cash or property) 12. Explain fully the circumstances of all payments, including the terms of any oral agreement or understanding pursuant to which they were made. Form LM-10 - Part B (2003) American LegalNet, Inc. www.USCourtForms.com