SEC 2270 Form 5 Annual Statement of Beneficial Ownership

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

FORM 5

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ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF

Check this box if no longer
SECURITIES
subject to Section 16. Form 4 or Form 5 obligations may continue.
See Instruction 1(b).
Form 3 Holdings Reported
Form 4 Transaction Reported
Check this box to indicate that a transaction was made pursuant to a contract, instruction or writte
plan that is intended to satisfy the affirmative defense conditions of Rule 10b5-1(c).
See Instruction 10.
(Print or Type Responses)

(Last)

(First)

(Middle)

(Street)

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

(State)

5. Relationship of Reporting Person(s) to Issuer

2. Issuer Name and Ticker or Trading Symbol

1. Name and Address of Reporting Person*

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

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

(Check all applicable)

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 any Code
(Month/
(Instr. 8)
Day/Year)

5. Amount of
Securities
Beneficially
Owned at the
end of Issuer's
Fiscal Year
(Instr. 3 and 4)

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

Amount

(A) or
(D)

Price

6. Owner- 7. Nature of
Indirect
ship
Beneficial
Form:
Ownership
Direct
(D) or
Indirect
(Instr. 4)
(I) (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 2270 (02-23)

FORM 5 (continued)
1. Title of Derivative 2. ConverSecurity
sion or
(Instr. 3)
Exercise
Price of
Derivative
Security

Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned
( e.g., puts, calls, warrants, options, convertible securities)
3. Trans- 3A. Deemed 4. Trans- 5. Number of Derivaction Execution
action
ative Securities
Date
Date, if
Code
Acquired (A) or
any
(Instr. 8)
Disposed of (D)
(Month/ (Month/
(Instr. 3, 4, and 5)
Day/
Day/
Year)
Year)

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

Date
Exercisable
(A)

Expiration
Date

7. Title and Amount of Underly- 8. Price 9. Number 10.Owner- 11. Nature
of
of derivship
of Indiing Securities
Deriv- ative
Form of
rect
(Instr. 3 and 4)
ative
SecurDerivBenSecurities
ative
eficial
ity
BeneSecuriOwner(Instr.
ficially
ties:
ship
5)
Owned
Direct
(Instr. 4)
at End of (D) or
Issuer's
Indirect
Fiscal
(I)
Amount or
Year
(Instr. 4)
Title
Number of
(Instr. 4)
Shares

(D)

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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