Form 5 Annual Statement Of Changes In Benificial Ownership Of Securities (SEC2270) {5} | Pdf Fpdf Doc Docx | Official Federal Forms

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Form 5 Annual Statement Of Changes In Benificial Ownership Of Securities (SEC2270) {5} | Pdf Fpdf Doc Docx | Official Federal Forms

Form 5 Annual Statement Of Changes In Benificial Ownership Of Securities (SEC2270) {5}

This is a Official Federal Forms form that can be used for Securities And Exchange Commission.

Alternate TextLast updated: 5/26/2017

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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: June 30, 2017 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) ____________________________ (check applicable line) (Street) 6. Individual or Joint/Group Reporting _____ 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. * If the form is filed by more than one reporting person, see instruction 4(b)(v). Potential persons who are to respond to the collection of informaAmerican 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. (Over) SEC 2270 (11-11) FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) Number 10. Owner- 11. Nature of of Deship Indirect rivative Form BenefiSecuriof Decial ties Benrivative Ownereficially Securiship (Instr. 4) Owned ties: at End of Direct Issuer's (D) or Fiscal Indirect Year (I) (Instr. 4) (Instr. 4) 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. Security sion or tive Securities Acable and Expiing Securities of tion action Execetion (Instr. 3) (Instr. 3 and 4) ExerDate, if quired (A) or Disration Date DeCode Date (Month/ (Instr. 8) (Month/Day/ cise any posed of (D) rivaYear) (Instr. 3, 4, and 5) Price of Day/ (Month/ tive Year) Day/ DerivaSecutive SeYear) rity (Instr. 5) curity Date Exercisable Expiration Date Amount or Number of Shares (A) (D) Title 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 provided is insufficient, see Instruction 6 for procedure. ** Signature of Reporting Person Date 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. American LegalNet, Inc. www.FormsWorkFlow.com Page 2

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