Form 6800-03 Initial Statement of Beneficial Ownership of Securities

FORM 3

Federal Deposit Insurance Corporation Washington, D.C. 20429 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 (PLEASE PRINT OR TYPE ALL RESPONSES)

OMB APPROVAL

OMB NUMBER: 3064-0030 EXPIRES: 09/30/2016 Estimated average burden hours per response ...1.0

1. Name of Reporting Person (Last, First, Middle)*

2. Date of Event Requiring Statement (Month/Day/Year)

4. Issuer Name and Ticker or Trading Symbol

     

     

     

Street Address      

3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)      

5. Relationship of Reporting Person to Issuer (Check all applicable)

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

Director

10% Owner

Officer (give title below)

Other (Specify below)

7. Individual or Joint/Group Filing (Check Applicable Box) Form filed by One Reporting Person Form filed by More than One Reporting Person

City

State

ZIP Code

     

     

     

     

Table I - Non-Derivative Securities Beneficially Owned

1. Title of Security (Instr. 4)

2. Amount of Securities Beneficially Owned (Instr. 4)

3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)

4. Nature of Indirect Beneficial Ownership (Instr. 5)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

FDIC 6800/03 (10-05) Reminder: Report on a Separate Line for each class of securities beneficially owned directly or indirectly. (Continue on Page 2)

*If the form is filed by more than one reporting person, see Instruction 5(b)(v). Page       of      -

FORM 3 (continued)
Table II - Derivative Securities Beneficially Owned (e.g., plus, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4)	2. Date Exercisable and Expiration Date (Month/Day/Year)		3. Title and Amount of Securities Underlying Derivative Security (Instr. 4)			4. Conversion or Exercise Price of Derivative Security		5. Ownership Form of Derivative Securities: Direct (D) or Indirect (I) (Instr. 5)		6. Nature of Indirect Beneficial Ownership (Instr. 5)
	Date Exercisable	Expiration Date	Title		Amount or Number of shares
     	     	     	     		     	     		     		     
     	     	     	     		     	     		     		     
     	     	     	     		     	     		     		     
     	     	     	     		     	     		     		     
     	     	     	     		     	     		     		     
     	     	     	     		     	     		     		     
     	     	     	     		     	     		     		     
     	     	     	     		     	     		     		     
     	     	     	     		     	     		     		     
     	     	     	     		     	     		     		     
Explanation of Responses:
     
				     
				**Signature of Reporting Person					Date
NOTE: File three copies of this Form, one of which must be manually signed. If the space provided is insufficient, see Instruction 6 for procedure (12 C.F.R. 335.611). Potential persons who are to respond to the collection of information contained on this form are not required to respond unless the form displays a current, valid OMB Control Number. **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
BURDEN STATEMENT Public reporting burden for this collection of information is estimated to average 1.0 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to, the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th St. NW, Washington, D.C. 20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0030), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection unless it displays a currently valid OMB control.

FDIC 6800/03 (10-05) Page 2 Page       of      -