Form 6800-03 Initial Statement of Beneficial Ownership of Securities

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Federal Deposit Insurance Corporation
Washington, D.C. 20429

FORM 3

OMB APPROVAL

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

OMB NUMBER: 3064-0030
EXPIRES: 01/31/2020
Estimated average burden
hours per response ...1.0

(PLEASE PRINT OR TYPE ALL RESPONSES)
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 5. Relationship of Reporting Person to Issuer (Check all
Reporting Person, if an Entity
applicable)
(Voluntary)
Director
10% Owner
Officer (give title below)

City

State

Other (Specify below)

ZIP Code

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

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

Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security
(Instr. 4)

FDIC 6800/03 (10-05)

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

Reminder:

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

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

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).

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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)

Date
Exercisable

Expiration
Date

3. Title and Amount of Securities Underlying Derivative
Security (Instr. 4)

4. Conversion
or Exercise
Price of
Derivative
Security
Amount or
Number of
shares

Title

5. Ownership 6. Nature of Indirect
Beneficial Ownership (Instr. 5)
Form of
Derivative
Securities:
Direct (D)
or Indirect
(I) (Instr. 5)

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

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