Form 6800-04 Statement of Changes in Beneficial Ownership of Securiti

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Federal Deposit Insurance Corporation

FORM 4

OMB APPROVAL

Washington, D.C. 20429

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

OMB NUMBER: 3064-0030
EXPIRES: 09/30/2016
Estimated average burden
hours per response ...0.5

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
(PLEASE PRINT OR TYPE ALL RESPONSES)

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

2. Issuer Name and Tickler or Trading Symbol

Street Address

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

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

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

Director

10% Owner

Officer (Give title below)

Other (Specify below)

6. Individual or Joint/Group Filing (Check applicable box)
Form filed by One Reporting Person
City

State

ZIP Code

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 6800/04 (10-05)

2. Transaction Date
(Month/Day/Year)

2A. Deemed
Execution Date
if any,
(Month/
Day/
Year)

3. Transaction
Code
(Instr. 8)

Code

V

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

Amount

(A) or (D)

Price

6. Ownership
7. Nature of Indirect
5. Amount of
Securities
Form
Beneficial Ownership
Beneficially
Direct (D) or
(Instr. 4)
Indirect (I)
Owned Following Reported
(Instr. 4)
Transactions
(Instr. 3 and 4)

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 4(b)(v).
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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
Security
(Instr. 3)

3. Trans- 3A. Deemed
2. Conaction
version
Execuor ExDate
tion
ercise
(Month/
Date
Price
Day/
if any,
of DeYear)
(Month/
rivative
Day/
SecuYear)
rity

4. Transaction
Code
(Instr. 8)

Code

V

5. Number of
Derivative
Securities
Acquired (A)
or
Disposed of
(D)
(Instrs. 3, 4,
and 5)

(A)

(D)

6. Date
Exercisable and
Expiration Date
(Month/
Day/Year)

Date Exercisable

Expiration
Date

11. Nature of
9. Number of 10. Owner8. Price
of
Indirect
Derivative
ship Form
Deof
Beneficial
Securities
rivative
DerivaOwnership
Beneficially
Security
tive
(Instr. 4)
Owned
(Instr. 5)
Securities:
Following
Direct (D)
Reported
or
TransIndirect (I)
action(s)
(Instr. 4)
(Instr. 4)
Amount or
Number of
Shares

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

Title

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. 335.612).
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 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 0.5 hour 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 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 6800/04 (10-05)

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