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Form 3 Initial Statement Of Beneficial Ownership Of Securities (SEC1473) 3 - Official Federal Forms
| Form 3 Initial Statement Of Beneficial Ownership Of Securities (SEC1473) Form. This is a national form and can be used in Securities And Exchange Commission . |
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You may not send a completed printout of this form to the SEC to satisfy a filing obligation. You can only satisfy an SEC filing obligation by submitting the information required by this form to the SEC in electronic format online at https://www.onlineforms.edgarfiling.sec.gov. FORM 3 (Print or Type Responses) 1. Name and Address of Reporting Person* UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 Form 3 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 2. Date of Event Requiring Statement (Month/Day/Year) (Middle) 3. Issuer Name and Ticker or Trading Symbol OMB APPROVAL OMB Number: 3235-0104 Expires: December 31, 2014 Estimated average burden hours per response. . . . . . 0.5 (Last) (First) 4. Relationship of Reporting Person(s) to Issuer (Check all applicable) 5. If Amendment, Date Original Filed (Month/Day/ Year) (Street) Director Officer (give title below) (Zip) 10% Owner Other (specify below) 6. Individual or Joint/Group Filing (Check Applicable Line) __Form filed by One Reporting Person __Form filed by More than One ReportingPerson (City) 1. Title of Security (Instr. 4) (State) Table I -- Non-Derivative Securities Beneficially Owned 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership 4. Nature of Indirect Beneficial Ownership Form: Direct (Instr. 5) (D) or Indirect (I) (Instr. 5) Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. * If the form is filed by more than one reporting person, see Instruction 5(b)(v). Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. (Over) SEC 1473 (11-11) American LegalNet, Inc. www.FormsWorkFlow.com FORM 3 (continued) 1. Title of Derivative Security (Instr. 4) Table II -- Derivative Securities Beneficially Owned ( e.g., puts, calls, warrants, options, convertible securities) 2. Date Exer cisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) Date Exer cisable Expira tion Date Title Amount or Number of Shares 4. Conver 5. Owner 6. Nature of Indirect ship sion or Beneficial Ownership Form of Exercise (Instr. 5) Deriv Price of ative Deri Security: vative Direct Security (D) or Indirect (I) (Instr. 5) Explanation of Responses: ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, See Instruction 6 for procedure. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. **Signature of Reporting Person Date Page 2 American LegalNet, Inc. www.FormsWorkFlow.com
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