Form 3 - Initial Statement of Beneficial Ownership of Securities

UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 3
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
The Commission is authorized to solicit the information required by this Form pursuant to
Sections 16(a) and 23(a) of the Securities Exchange Act of 1934, and Sections 30(h) and 38
of the Investment Company Act of 1940, and the rules and regulations thereunder.
Disclosure of information specified on this Form is mandatory. The information will be
used for the primary purpose of disclosing the holdings of directors, officers, and beneficial
owners of registered companies. Information disclosed will be a matter of public record
and available for inspection by members of the public. The Commission can use it in
investigations or litigation involving the federal securities laws or other civil, criminal, or
regulatory statutes or provisions, as well as for referral to other governmental authorities
and self-regulatory organizations. Failure to disclose required information may result in
civil or criminal action against persons involved for violations of the federal securities laws
and rules.

SEC 1472 (05-19)

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.

GENERAL INSTRUCTIONS
1.

Who Must File
(a)

This Form must be filed by the following persons (“reporting person”):

(i)
any director or officer of an issuer with a class of equity securities
registered pursuant to Section 12 of the Securities Exchange Act of 1934 (“Exchange Act”);
(Note: Title is not determinative for purposes of determining “officer” status. See Rule 16a-1(f)
for the definition of “officer”).
(ii)
any beneficial owner of greater than 10% of a class of equity securities
registered under Section 12 of the Exchange Act, as determined by voting or investment control
over the securities pursuant to Rule 16a-1(a)(l) (“ten percent holder”).
(iii)

[Reserved]

(iv)
any officer, director, member of an advisory board, investment adviser,
affiliated person of an investment adviser or beneficial owner of more than 10% of any class of
outstanding securities (other than short-term paper) of a registered closed-end investment
company, under Section 30(h) of the Investment Company Act of 1940; and
(v)

16a-8.

any trust, trustee, beneficiary or settlor required to report pursuant to Rule

(b)
If a reporting person is not an officer, director, or ten percent holder, the person
should check “other” in Item 5 (Relationship of Reporting Person to Issuer) and describe the
reason for reporting status in the space provided.
(c)
If a person described above does not beneficially own any securities required to
be reported (See Rule 16a-1 and Instruction 5), the person is required to file this Form and state
that no securities are beneficially owned.
2.

When Form Must be Filed

(a)
This Form must be filed within 10 days after the event by which the person
becomes a reporting person (i.e., officer, director, ten percent holder or other person). This Form
and any amendment is deemed filed with the Commission or the Exchange on the date it is
received by the Commission or the Exchange, respectively. See, however, Rule 16a-3(h)
regarding delivery to a third party business that guarantees delivery of the filing no later than the
specified due date.
(b)
A reporting person of an issuer that is registering securities for the first time under
Section 12 of the Exchange Act must file this Form no later than the effective date of the
registration statement.
issuer.

(c)

A separate Form shall be filed to reflect beneficial ownership of securities of each

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3.

Where Form Must be Filed

(a)
A reporting person must file this Form in electronic format via the Commission’s
Electronic Data Gathering Analysis and Retrieval System (EDGAR) in accordance with EDGAR
rules set forth in Regulation S-T (17 CFR Part 232), except that a filing person that has obtained
a hardship exception under Regulation S-T Rule 202 (17 CFR 232.202) may file the Form in
paper. For assistance with technical questions about EDGAR or to request an access code, call
the EDGAR Filer Support Office at (202) 942-8900. For assistance with questions about the
EDGAR rules, call the Office of EDGAR and Information Analysis at (202) 942-2940.
(b)
At the time this Form or any amendment is filed with the Commission, file one
copy with each Exchange on which any class of securities of the issuer is registered. If the issuer
has designated a single Exchange to receive Section 16 filings, the copy shall be filed with that
Exchange only
(c)

[Reserved]

Note: If filing pursuant to a hardship exception under Regulation S-T Rule 202 (17 CFR
232.202), file three copies of this Form or any amendment, at least one of which is signed, with
the Securities and Exchange Commission, 450 5th Street, NW, Washington, DC 20549.
(Acknowledgement of receipt by the Commission may be obtained by enclosing a self-addressed
stamped postcard identifying the Form or amendment filed.)
4.

Class of Securities Reported

(a)
(i)
Persons reporting pursuant to Section 16(a) of the Exchange Act shall
include information as to their beneficial ownership of any class of equity securities of the issuer,
even though one or more of such classes may not be registered pursuant to Section 12 of the Act.
(ii)

[Reserved]

(iii) Persons reporting pursuant to Section 30(h) of the Investment Company
Act of 1940 shall include information as to their beneficial ownership of any class of securities
(equity or debt) of the registered closed-end investment company (other than “short-term paper”
as defined in Section 2(a)(38) of the Investment Company Act).
(b)
The title of the security should clearly identify the class, even if the issuer has
only one class of securities outstanding: for example, “Common Stock,” “Class A Common
Stock,” “Class B Convertible Preferred Stock,” etc.
(c)
The amount of securities beneficially owned should state the face amount of debt
securities (U.S. Dollars) or the number of equity securities, whichever is appropriate.

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5.

Holdings Required to be Reported

(a)
General Requirements. Report holdings of each class of securities of the issuer
beneficially owned as of the date of the event requiring the filing of this Form. See Instruction as
to securities required to be reported.
(b)

Beneficial Ownership Reported (Pecuniary Interest).

(i)
Although for purposes of determining status as a ten percent holder, a
person is deemed to beneficially own securities over which that person has voting or investment
control (see Rule 16a-1(a)(1)), for reporting purposes, a person is deemed to be the beneficial
owner of securities if that person has or shares the opportunity, directly or indirectly, to profit or
share in any profit derived from a transaction in the securities (“pecuniary interest”). See Rule
16a-1(a)(2). See also Rule 16a-8 for the application of the beneficial ownership definition to trust
holdings and transactions.
(ii)
Both direct and indirect beneficial ownership of securities shall be
reported. Securities beneficially owned directly are those held in the reporting person’s name or
in the name of a bank, broker or nominee for the account of the reporting person. In addition,
securities held as joint tenants, tenants in common, tenants by the entirety, or as community
property are to be reported as held directly. If a person has a pecuniary interest, by reason of any
contract, understanding or relationship (including a family relationship or arrangement) in
securities held in the name of another person, that person is an indirect beneficial owner of those
securities. See Rule 16a-1(a)(2)(ii) for certain indirect beneficial ownerships.
(iii) Report securities beneficially owned directly on a separate line from those
beneficially owned indirectly. Report different forms of indirect ownership on separate lines. The
nature of indirect ownership shall be stated as specifically as possible; for example, “By Self as
Trustee for X,” “By Spouse,” “By X Trust,” “By Y Corporation,” etc.
(iv)
In stating the amount of securities owned indirectly through a partnership
corporation, trust, or other entity, report the number of securities representing the reporting
person’s proportionate interest in securities beneficially owned by that entity. Alternatively, at the
option of the reporting person, the entire amount of the entity’s interest may be reported. See
Rule 16a-1(a)(2)(ii)(B) and Rule 16a-1(a)(2)(iii).
(v)
Where more than one person beneficially owns the same equity securities,
such owners may file Form 3 individually or jointly. Joint and group filings may be made by any
designated beneficial owner. Holdings of securities owned separately by any joint or group filer
are permitted to be included in the joint filing. Indicate only the name and address of the
designated filer in Item 1 of Form 3 and attach a list of the names and addresses of each other
reporting person. Joint and group filings must include all required information for each beneficial
owner, and such filings must be signed by each beneficial owner, or on behalf of such owner by
an authorized person.
If this Form is being filed in paper pursuant to a hardship exemption and
the space provided for signatures is insufficient, attach a signature page. If this Form is being
filed in paper, submit any attached listing of names or signatures on another Form 3, copy of
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Form 3 or separate page of 8 ½ by 11 inch white paper, indicate the number of pages comprising
the report (Form plus attachments) at the bottom of each report page (e.g., 1 of 3, 2 of 3, 3 of 3),
and include the name of the designated filer and information required by Items 2 and 3 of the
Form on the attachment.
See Rule 16a-3(i) regarding signatures.
(c)

Non-Derivative and Derivative Securities.

(i)
Report non-derivative securities beneficially owned in Table I and
derivative securities (e.g., puts, calls, options, warrants, convertible securities, or other rights or
obligations to buy or sell securities) beneficially owned in Table II. Derivative securities
beneficially owned that are both equity securities and convertible or exchangeable for other
equity securities (e.g., convertible preferred securities) should be reported only on Table II.
(ii)
The title of a derivative security and the title of the equity security
underlying the derivative security should be shown separately in the appropriate columns in
Table II. The “puts” and “calls” reported in Table II include, in addition to separate puts and
calls, any combination of the two, such as spreads and straddles. In reporting an option in Table
II, state whether it represents a right to buy, a right to sell, an obligation to buy, or an obligation
to sell the equity securities subject to the option.
(iii) Describe in the appropriate columns in Table II characteristics of
derivative securities, including title, exercise or conversion price, date exercisable, expiration
date, and the title and amount of securities underlying the derivative security.
(iv)
Securities constituting components of a unit shall be reported separately
on the applicable table (e.g., if a unit has a non-derivative security component and a derivative
security component, the non-derivative security component shall be reported in Table I and the
derivative security component shall be reported in Table II). The relationship between individual
securities comprising the unit shall be indicated in the space provided for explanation of
responses.
6.

Additional Information

(a)
If the space provided in the line items on the electronic Form is insufficient, use
the space provided for footnotes. If the space provided for footnotes is insufficient, create a
footnote that refers to an exhibit to the Form that contains the additional information.
(b)
If the space provided in the line items on the paper Form or space provided for
additional comments is insufficient, attach another Form 3, copy of Form 3 or separate 8 ½ by 11
inch white paper to Form 3, completed as appropriate to include the additional comments. Each
attached page must include information required in Items 1, 2 and 3 of the Form. The number of
pages comprising the report (Form plus attachments) shall be indicated at the bottom of each
report page (e.g., 1 of 3, 2 of 3, 3 of 3).
(c)
If one or more exhibits are included, whether due to a lack of space or because the
exhibit is, by nature, a separate document (e.g., a power of attorney), provide a sequentially
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numbered list of the exhibits in the Form. Use the number “24” for any power of attorney and the
number “99” for any other exhibit. If there is more than one of either such exhibit, then use
numerical subparts. If the exhibit is being filed as a confirming electronic copy under
Regulations S-T Rule 202(d) (17 CFR 232.202(d)), then place the designation “CE” (confirming
exhibit) next to the name of the exhibit in the exhibit list. If the exhibit is being filed in paper
pursuant to a hardship exception under Regulation S-T Rule 202 (17 CFR 232.202), then place
the designation “P” (paper) next to the name of the exhibit in the exhibit list.
(d)
If additional information is not reported as provided in paragraph (a), (b) or (c) of
this instruction, whichever apply, it will be assumed that no additional information was provided.
7.

Signature

(a)
If the Form is filed for an individual, it shall be signed by that person or
specifically on behalf of the individual by a person authorized to sign for the individual. If signed
on behalf of the individual by another person, the authority of such person to sign the Form shall
be confirmed to the Commission in writing in an attachment to the Form or as soon as
practicable in an amendment by the individual for whom the Form is filed, unless such a
confirmation still in effect is on file with the Commission. The confirming statement need only
indicate that the reporting person authorizes and designates the named person or persons to file
the Form on the reporting person’s behalf, and state the duration of the authorization.
(b)
If the Form is filed for a corporation, partnership, trust, or other entity, the
capacity in which the individual signed shall be set forth (e.g., John Smith, Secretary, on behalf
of X Corporation).
8.

Amendments

(a)
If this Form is filed as an amendment in order to add one or more lines of
ownership information to Table I or Table II of the Form being amended, provide each line being
added, together with one or more footnotes, as necessary, to explain the addition of the line or
lines. Do not repeat lines of ownership information that were disclosed in the original Form and
are not being amended.
(b)
If this Form is filed as an amendment in order to amend one or more lines of
ownership information that already were disclosed in Table I or Table II of the Form being
amended, provide the complete line or lines being amended, as amended, together with one or
more footnotes, as necessary, to explain the amendment of the line or lines. Do not repeat lines of
ownership information that were disclosed in the original Form and are not being amended.
(c)
If this Form is filed as an amendment for any purpose other than or in addition to
the purposes described in paragraphs (a) and (b) of this General Instruction 8, provide one or
more footnotes, as necessary, to explain the amendment.

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