Form 6800-05 Annual Statement of Beneficial Ownership of Securities

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Federal Deposit Insurance Corporation
Washington, D.C. 20429

FORM 5
Check box if no longer subject to Section 16.
Form 4 or Form 5 obligations may continue.
See instruction 1(b).

OMB APPROVAL

ANNUAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934

Form 3 holdings reported.

hours per response ...1.0

(PLEASE PRINT OR TYPE ALL RESPONSES)

Form 4 transactions reported.

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

2. Issuer Name and Ticker or Trading Symbol

Street Address

3. Statement for Issuer’s Fiscal
Year Ended (Month/Day/Year)

OMB NUMBER: 3064-0030
EXPIRES: 01/31/2020
Estimated average burden

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

10% Owner

Officer (Give title below)

Other (Specify below)

4. If Amendment, Date Original
Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check applicable box)

City

State

ZIP Code

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
1. Title of Security
(Instr. 3)

FDIC 6800/05 (10-05)

2. Transaction Date 2A. Deemed
3. Transaction 4. Securities Acquired (A) or Disposed
Code
Month/Day/Year)
Execution
of (D) (Instrs. 3, 4, and 5)
(Instr. 8)
Date, if any
(Month/
Day/
Year)
Amount
(A) or (D)
Price

Reminder:

5. Amount of Securities
Beneficially Owned
at End of Bank's
Fiscal Year
(Instrs. 3. and 4.)

6. Ownership Form
Direct (D)
Indirect(I) or
(Instr. 4)

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

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 4(b)(v)
Page ______ of

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 Security 2. Con(Instr. 3)
version
or Exercise
Price
of Derivative
Security

6. Date
3. Trans3A. Deem- 4. Trans- 5. Number of
Exercisable and
ed
action
action
Derivative
Expiration Date
ExecuDate
Code
Securities
(Instr. 8)
(Month/Day/Year)
tion
(Month/
Acquired (A) or
Disposed of (D)
Date, if
Day/
(Instrs. 3, 4,
any
Year)
and 5)
(Month/
Day/
Year)

(A)

(D)

Date
Expiration
Exercisable
Date

7. Title and
Amount
of Underlying
Securities
(Instrs. 3
and 4)

Title

9. Number
8. Price
10. Ownerof
ship
of
DeForm
Derivative
rivative
of
Securities
Security
DerivaBeneficiall
tive
(Instr. 5)
y Owned
Securat End of
ities:
Issuer’s
Direct
Fiscal
(D)
Year
or
(Instr. 4)
Indirect
(I)
(Instr.4)

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

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 space provided is insufficient, see Instruction 6 for procedure (12 C.F.R. 335.613).
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 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 the Office of Management and Budget, Paperwork Reduction Project (3064-0030), Washington, D.C. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number.

FDIC 6800/05 (10-05) Page 2