SEC Form 4

UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

FORM 4
Check this box if no longer
subject to Section 16. Form 4 or
Form 5 obligations may continue.
See Instruction 1(b).
(Print or Type Responses)

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STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility
Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940

1. Name and Address of Reporting Person*

5. Relationship of Reporting Person(s) to Issuer

2. Issuer Name and Ticker or Trading Symbol

(Check all applicable)

(Last)

(First)

(Middle)

(Street)

(City)
1. Title of Security
(Instr. 3)

(State)

(Zip)
2. Transaction
Date
(Month/
Day/
Year)

3. Date of Earliest
Transcaction Required
to be Reported
(Month/Day/Year)

4. If Amendment,
Date Original
Filed(Month/Day/Year)

Director
Officer (give
title below)

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 Reporting Person

Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
2A. Deemed 3. TransExecution
action
Date, if
Code
any
(Instr. 8)
(Month/
Day/Year)
Code

V

4. Securities Acquired (A)
or Disposed of (D)
(Instr. 3, 4 and 5)

Amount

(A) or
(D)

Price

5. Amount of
6. Owner- 7. Nature of
Securities
ship
Indirect
Beneficially
Form:
Beneficial
Owned
Direct
OwnerFollowing
(D) or
ship
Reported
Indirect
Transaction (s)
(I)
(Instr. 3 and 4)
(Instr. 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
information contained in this form are not required to respond
unless the form displays a currently valid OMB control number.

(Over)
SEC 1474 (01-05)

FORM 4 (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. Trans- 5.
Security
sion or
action Execution
action
(Instr. 3)
Exercise Date
Date, if
Code
Price of
any
(Instr. 8)
Deri(Month/ (Month/
vative Day/
Day/
Security Year)
Year)

Date
Exercisable
Code V

8. Price 9. Number 10.Owner- 11. Nature
of
of deriv- ship
of
Derivative
Form of
Indirect
ative
SecurDerivBenefiSecurities
ative
cial
ity
BeneSecurity:
Owner(Instr.
ficially
Direct
ship
5)
Owned
(D) or
(Instr. 4)
followIndirect
ing
(I)
Re(Instr. 4)
Amount or
ported
Number of
Transaction
Shares
(s)(Instr.
4)

7. Title and Amount of
Number of Deriv- 6. Date ExerUnderlying Securities
cisable and
ative Securities Ac(Instr. 3 and 4)
Expiration
quired (A) or DisDate
posed of (D)
(Month/Day/
(Instr. 3, 4, and 5)
Year)

(A)

(D)

Expiration
Date

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).

**Signature of Reporting Person

Date

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.
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