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Form 5 Annual Statement Of Changes In Benificial Ownership Of Securities (SEC2270) 5 - Official Federal Forms
| Form 5 Annual Statement Of Changes In Benificial Ownership Of Securities (SEC2270) 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 5 Check box if no longer subject to Section 16. Form 4 or Form 5 obli gations may continue. See Instruc tion 1(b). Form 3 Holdings Reported Form 4 Transactions Reported UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES 2. Issuer Name and Ticker or Trading Symbol OMB APPROVAL OMB Number: 3235-0362 Expires: January 31,2014 Estimated average burden hours per response. . . . . . . 1.0 1. Name and Address of Reporting Person* (Last) (First) (Middle) 3. Statement for Issuer's Fiscal Year Ended (Month//Day/Year) 4. If Amendment, Date Original Filed (Month/Day/Year) 5. Relationship of Reporting Person(s) to Issuer (Check all applicable) _____ Director _____ 10% Owner _____ Officer (give _____ Other (specify title below) below) ____________________________ 6. Individual or Joint/Group Reporting (check applicable line) (Street) _____ Form Filed by One Reporting Person _____ Form Filed by More than One Reporting Person (City) 1. Title of Security (Instr. 3) (State) (Zip) 2. Transaction Date (Month/ Day/ Year) Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned 2A.Deemed 3. Trans- 4. Securities Acquired (A) or Disposed of (D) action Execu(Instr. 3, 4 and 5) Code tion (Instr. 8) Date, if any (Month/ (A) or Day/ Amount (D) Year) 6. Owner- 7. Nature of 5. Amount of ship Indirect Securities BenForm: DiBeneficial eficially Owned rect (D) Ownership at end of (Instr. 4) or IndiIssuer's Fiscal rect (I) Year Price (Instr. 3 and 4) (Instr. 4) Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. Potential persons who are to respond to the collection of informa* If the form is filed by more than one reporting person, see instruction 4(b)(v). (Over) SEC 2270 (11-11) American LegalNet, Inc. www.FormsWorkFlow.com tion contained in this form are not required to respond unless the form displays a currently valid OMB control number. FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) 1. Title of Derivative 2. Conver 3. Trans 3A.Deemed 4. Transac 5. Number of Deriva 6. Date Exercis 7. Title and Amount of Underly 8. Price 9. Number 10. Owner 11. Nature of Security sion or tive Securities Ac able and Expi of De ship Indirect ing Securities of tion action Execetion (Instr. 3) (Instr. 3 and 4) Exer Date, if quired (A) or Dis ration Date rivative Form Benefi De Code Date (Month/ (Instr. 8) (Month/Day/ cise any posed of (D) Securi of De cial riva Year) (Instr. 3, 4, and 5) Price of Day/ (Month/ ties Ben rivative Owner tive Year) Day/ Deriva eficially Securi ship Secu (Instr. 4) tive Se Year) Owned ties: rity (Instr. 5) curity at End of Direct Issuer's (D) or Fiscal Indirect Date Expira Amount or Year (I) Exer tion Number of (Instr. (Instr. 4) cisable Date Title Shares 4) (A) (D) 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). ** Signature of Reporting Person Date Note: File three copies of this Form, one of which must be manually signed. If space provided 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. Page 2 American LegalNet, Inc. www.FormsWorkFlow.com
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