Form C-4 Notification and Report Form for Certain Mergers and Acq

TRANSACTION NUMBER ASSIGNED

Approved by OMB
3084-0005
Expires 05/31/2007

16 C.F.R. Part 803 - Appendix
NOTIFICATION AND REPORT FORM FOR CERTAIN MERGERS AND ACQUISITIONS

THE INFORMATION REQUIRED TO BE SUPPLIED ON THESE ANSWER SHEETS IS SPECIFIED IN THE INSTRUCTIONS
È Attach the Affidavit required by § 803.5 to this page.
FEE INFORMATION

TAXPAYER IDENTIFICATION NUMBER
or SOCIAL SECURITY NUMBER of payer
(acquiring person (and payer if different from acquiring person))
AMOUNT PAID
$

MONEY ORDER ATTACHED
In cases where your filing fee would be higher if
CHECK ATTACHED

CONFIRMATION NO.
based on acquisition price or where the acquisition WIRE TRANSFER
price is undetermined to the extent that it may
FROM: NAME OF INSTITUTION
straddle a filing fee threshold, attach an explanation
NAME OF PAYER (if different from PERSON FILING)

of how you determined the appropriate fee

(acquiring persons only).
Attachment Number

IS THIS A CORRECTIVE FILING?

… YES

_

_

… NO

IS THIS ACQUISITION SUBJECT TO FOREIGN FILING REQUIREMENTS?
If YES, list jurisdictions: (voluntary)
IS THIS ACQUISITION A CASH TENDER OFFER?

… YES

… NO

… YES
BANKRUPTCY?

… NO
… YES

… NO

DO YOU REQUEST EARLY TERMINATION OF THE WAITING PERIOD? (Grants of early termination are published in the Federal Register AND
… YES
… NO
on the FTC web site www.ftc.gov)
ITEM 1 – PERSON FILING
1(a) NAME and
HEADQUARTERS ADDRESS
of PERSON FILING
1(b) PERSON FILING NOTIFICATION IS
… an acquiring person
… an acquired person

… both

1(c) PUT AN "X" IN THE APPROPRIATE BOX TO DESCRIBE PERSON FILING NOTIFICATION
… Corporation
… Unincorporated Entity
… Other (Specify):
1(d) DATA FURNISHED BY

… calendar year

… fiscal year (specify period )

(month/year) to

(month/year)

THIS FORM IS REQUIRED BY LAW and must be filed separately by each person
which, by reason of a merger, consolidation or acquisition, is subject to §7A of the
Clayton Act, 15 U.S.C. §18a, as added by Section 201 of the Hart-Scott-Rodino
Antitrust Improvements Act of 1976, Pub. L. No. 94-435, 90 Stat. 1390, and rules
promulgated thereunder (hereinafter referred to as "the rules" or by section number).
The statute and rules are set forth in the Federal Register at 43 FR 33450; the rules
may also be found at 16 CFR Parts 801-03. Failure to file this Notification and
Report Form, and to observe the required waiting period before consummating the
acquisition in accordance with the applicable provisions of 15 U.S.C. §18a and the
rules, subjects any "person," as defined in the rules, or any individuals responsible for
noncompliance, to liability for a penalty of not more than $11,000 for each day during
which such person is in violation of 15 U.S.C. §18a.

Pursuant to the Hart-Scott-Rodino Act, information and documentary material filed in
or with this Form is confidential. It is exempt from disclosure under the Freedom of
Information Act, and may be made public only in an administrative or judicial
proceeding, or disclosed to Congress or to a duly authorized committee or
subcommittee of Congress.

DISCLOSURE NOTICE - Public reporting burden for this report is estimated to vary
from 8 to 160 hours per response, with an average of 39 hours per response,
including 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 the burden estimate or any other aspect of
this report, including suggestions for reducing this burden to:
Premerger Notification Office, H-303, Federal Trade Commission,
Washington, DC 20503 and
Office of Information and Regulatory Affairs, Office of Management and Budget,
Washington, DC 20580

Privacy Act Statement--Section 18a(a) of Title 15 of the U.S. Code authorizes
the collection of this information. Our authority to collect Social Security
numbers is 31 U.S.C. 7701. The primary use of information submitted on this
Form is to determine whether the reported merger or acquisition may violate
the antitrust laws. Taxpayer information is collected, used, and may be shared
with other agencies and contractors for payment processing, debt collection
and reporting purposes. Furnishing the information on the Form is voluntary.
Consummation of an acquisition required to be reported by the statute cited
above without having provided this information may, however, render a person
liable to civil penalties up to $11,000 per day. We also may be unable to
process the Form unless you provide all of the requested information.

Under the Paperwork Reduction Act, as amended, 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. That
number is 3084-0005, which also appears in the upper right-hand corner of the
first page of this form.

FTC FORM C4 (rev. 06/06/06)

Filing - Complete and return two copies (with one original affidavit and certification
and one set of documentary attachments) of this Notification and Report Form to:
Premerger Notification Office, Bureau of Competition, Room 303, Federal Trade
Commission, 600 Pennsylvania Avenue, N.W., Washington, D.C. 20580. Three
copies (with one set of documentary attachments) should be sent to: Director of
Operations and Merger Enforcement, Antitrust Division, Department of Justice, 950
Pennsylvania Avenue N.W., Room #3335, Washington, D.C. 20530. (For FEDEX
airbills to the Department of Justice do not use the 20530 zip code; use zip code
20004.)

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NAME OF PERSON FILING NOTIFICATION

DATE

1(e) PUT AN X IN THE APPROPRIATE BOX AND GIVE THE NAME AND ADDRESS OF ENTITY FILING NOTIFICATION (if other than ultimate parent entity)

… NA

… This report is being filed on behalf of a foreign person

… This

report is being filed on behalf of the ultimate parent entity by
another entity within the same person authorized by it to file
pursuant to § 803.2(a).

pursuant to § 803.4.

ADDRESS

NAME OF ENTITY FILING NOTIFICATION

1(f) NAME AND ADDRESS OF ENTITY MAKING ACQUISITION OR WHOSE ASSETS, VOTING SECURITIES OR NON-CORPORATE INTERESTS ARE
BEING ACQUIRED IF DIFFERENT FROM THE ULTIMATE PARENT ENTITY IDENTIFIED IN ITEM 1(a)

PERCENT OF VOTING SECURITIES OR NON-CORPORATE INTERESTS HELD BY EACH ENTITY IDENTIFIED IN ITEM 1(a)

1(g) IDENTIFICATION OF PERSON TO CONTACT REGARDING THIS REPORT
NAME OF CONTACT PERSON
TITLE
FIRM NAME
BUSINESS ADDRESS
TELEPHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS

(h) IDENTIFICATION OF AN INDIVIDUAL LOCATED IN THE UNITED STATES DESIGNATED FOR THE LIMITED PURPOSE OF
RECEIVING NOTICE OF ISSUANCE OF A REQUEST FOR ADDITIONAL INFORMATION OR DOCUMENTS. (See § 803.20(b)(2)(iii))
NAME OF CONTACT PERSON
TITLE
FIRM NAME
BUSINESS ADDRESS
TELEPHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS

ITEM 2
2(a) LIST NAMES OF ULTIMATE PARENT ENTITIES OF ALL ACQUIRING
PERSONS

LIST NAMES OF ULTIMATE PARENT ENTITIES OF ALL ACQUIRED PERSONS

2(b) THIS ACQUISITION IS (put an X in all the boxes that apply)
… an acquisition of assets
… a merger (see § 801.2)
… an acquisition subject to § 801.2(e)
… a formation of a joint venture or other corporation or
unincorporated entity (see § 801.40 or § 801.50)
… an acquisition subject to § 801.30 (specify type)
… other (specify)

a consolidation (see § 801.2)
an acquisition of voting securities
a secondary acquisition
an acquisition subject to § 801.31
acquisition of non-corporate interests

2(c) INDICATE THE HIGHEST NOTIFICATION THRESHOLD IN § 801.1(h) FOR WHICH THIS FORM IS BEING FILED (acquiring person only in an
acquisition of voting securities)
… $50 million
… $100 million
… $500 million
… 25% (see Instructions)
… 50%

(as adjusted)
(as adjusted)
(as adjusted)
(as adjusted)

2(d)(i) VALUE OF VOTING
(ii) PERCENTAGE OF
(iii) VALUE OF ASSETS TO
(iv) VALUE OF NONCORPORATE (v) AGGREGATE TOTAL
SECURITIES TO BE HELD AS VOTING SECURITIES
BE HELD AS A RESULT OF
INTERESTS TO BE HELD AS A
VALUE
A RESULT OF THE
THE ACQUISITION
RESULT OF THE ACQUISITION
ACQUISITION

$
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%

$

$
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$

NAME OF PERSON FILING NOTIFICATION

DATE

2(e) If aggregate total value in 2(d)(v) is based in whole or in part on a fair market valuation pursuant to § 801.10(c)(3), identify the person or
persons responsible for making the valuation (acquiring persons only).

ITEM 3
3(a) DESCRIPTION OF ACQUISITION

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NAME OF PERSON FILING NOTIFICATION

DATE

3(b)(i) ASSETS TO BE ACQUIRED (to be completed only for asset acquisitions)

3(b)(ii) ASSETS HELD BY ACQUIRING PERSON

3(b)(iii) ASSETS HELD BY UNINCORPORATED ENTITIES

3(c) VOTING SECURITIES TO BE ACQUIRED
3(c)(i) LIST AND DESCRIPTION OF VOTING SECURITIES AND LIST OF NON-VOTING SECURITIES:

3(c)(ii) TOTAL NUMBER OF SHARES OF EACH CLASS OF SECURITY:

3(c)(iii) TOTAL NUMBER OF SHARES OF EACH CLASS OF SECURITY BEING ACQUIRED:

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NAME OF PERSON FILING NOTIFICATION

DATE

3(c)(iv) IDENTITY OF PERSONS ACQUIRING SECURITIES:

3(c)(v) DOLLAR VALUE OF SECURITIES IN EACH CLASS BEING ACQUIRED:

3(c)(vi) TOTAL NUMBER OF EACH CLASS OF SECURITIES TO BE HELD AS A RESULT OF THE ACQUISITION:

3(d) SUBMIT A COPY OF THE MOST RECENT VERSION OF CONTRACT OR AGREEMENT (or letter of intent to merge or acquire)

DO NOT ATTACH THIS DOCUMENT TO THIS PAGE

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ATTACHMENT OR REFERENCE NUMBER OF CONTRACT OR AGREEMENT ______________

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NAME OF PERSON FILING NOTIFICATION

DATE

ITEM 4 PERSONS FILING NOTIFICATION MAY PROVIDE BELOW AN OPTIONAL INDEX OF DOCUMENTS REQUIRED TO BE SUBMITTED BY ITEM 4
(See Item by Item instructions). THESE DOCUMENTS SHOULD NOT BE ATTACHED TO THIS PAGE.
4(a) DOCUMENTS FILED WITH THE UNITED STATES SECURITIES AND EXCHANGE COMMISSION

ATTACHMENT OR REFERENCE NUMBER

4(b) ANNUAL REPORTS, ANNUAL AUDIT REPORTS, AND REGULARLY PREPARED BALANCE SHEETS

ATTACHMENT OR REFERENCE NUMBER

4(c) STUDIES, SURVEYS, ANALYSES, AND REPORTS

ATTACHMENT OR REFERENCE NUMBER

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NAME OF PERSON FILING NOTIFICATION

DATE

ITEM 5 (See "References" listed in the General Instructions to the Form. Refer to the North American Industry Classification
System-United States, 2002 (2002 NAICS Manual) for the 6-digit (NAICS) industry codes. Refer to the 2002 Numerical List of
Manufactured and Mineral Products (EC02M31R-NL) for the 7-digit product class codes and the 10-digit product codes. Report
revenues for the 7-digit product class codes and 10-digit product codes using the codes in the columns labeled "Product code."
For further information on NAICS-based codes visit the www.census.gov web site.)
5(a) DOLLAR REVENUES BY INDUSTRY
6-DIGIT
INDUSTRY CODE

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DESCRIPTION

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2002 TOTAL
DOLLAR REVENUES

NAME OF PERSON FILING NOTIFICATION

DATE

ITEM 5(b)(i) DOLLAR REVENUES BY MANUFACTURED PRODUCTS
10-DIGIT
PRODUCT CODE

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DESCRIPTION

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2002 TOTAL
DOLLAR REVENUES

NAME OF PERSON FILING NOTIFICATION

DATE

ITEM 5(b)(ii) PRODUCTS ADDED OR DELETED

DESCRIPTION (10-DIGIT PRODUCT CODE)

ADD

DELETE

YEAR
OF
CHANGE

TOTAL DOLLAR
REVENUES

ITEM 5(b)(iii) DOLLAR REVENUES BY MANUFACTURED PRODUCT CLASS
7-DIGIT
PRODUCT CLASS

DESCRIPTION

(Item 5(b)(iii) continued on page 10)

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YEAR
I____________I
TOTAL DOLLAR REVENUES

NAME OF PERSON FILING NOTIFICATION

DATE

ITEM 5(b)(iii) DOLLAR REVENUES BY MANUFACTURED PRODUCT CLASS - CONTINUED
7-DIGIT
PRODUCT CLASS

DESCRIPTION

YEAR
I____________I
TOTAL DOLLAR REVENUES

ITEM 5(c) DOLLAR REVENUES BY NON-MANUFACTURING INDUSTRY
6-DIGIT
INDUSTRY CODE

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DESCRIPTION

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YEAR
I____________I
TOTAL DOLLAR REVENUES

NAME OF PERSON FILING NOTIFICATION

DATE

5(d) COMPLETE ONLY IF ACQUISITION IS IN THE FORMATION OF A JOINT VENTURE CORPORATION OR UNINCORPORATED ENTITY.
5(d)(i) NAME AND ADDRESS OF THE JOINT VENTURE CORPORATION OR UNINCORPORATED ENTITY

5(d)(ii)
(A) CONTRIBUTIONS THAT EACH PERSON FORMING THE JOINT VENTURE CORPORATION OR UNINCORPORATED ENTITY
HAS AGREED TO MAKE

(B) DESCRIPTION OF ANY CONTRACTS OR AGREEMENTS

(C) DESCRIPTION OF ANY CREDIT GUARANTEES OR OBLIGATIONS

(D) DESCRIPTION OF CONSIDERATION WHICH EACH PERSON FORMING THE JOINT VENTURE CORPORATION OR
UNINCORPORATED ENTITY WILL RECEIVE

5(d)(iii) DESCRIPTION OF THE BUSINESS IN WHICH THE JOINT VENTURE CORPORATION OR UNINCORPORATED ENTITY WILL ENGAGE

5(d)(iv) SOURCE OF DOLLAR REVENUES BY 6-DIGIT INDUSTRY CODE (non-manufacturing) AND BY 7-DIGIT PRODUCT CLASS (manufacturing)

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NAME OF PERSON FILING NOTIFICATION

DATE

ITEM 6
6(a) ENTITIES WITHIN PERSON FILING NOTIFICATION

6(b) SHAREHOLDERS OF PERSON FILING NOTIFICATION

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NAME OF PERSON FILING NOTIFICATION

DATE

6(c) HOLDINGS OF PERSON FILING NOTIFICATION

ITEM 7 DOLLAR REVENUES
7(a) 6-DIGIT NAICS CODE AND DESCRIPTION

7(b) NAME OF EACH PERSON WHICH ALSO DERIVED DOLLAR REVENUES

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NAME OF PERSON FILING NOTIFICATION

DATE

7(c) GEOGRAPHIC MARKET INFORMATION

ITEM 8

PRIOR ACQUISITIONS (to be completed by acquiring person only)

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NAME OF PERSON FILING NOTIFICATION

DATE

CERTIFICATION

This NOTIFICATION AND REPORT FORM, together with any and all appendices and attachments thereto, was
prepared and assembled under my supervision in accordance with instructions issued by the Federal Trade
Commission. Subject to the recognition that, where so indicated, reasonable estimates have been made because
books and records do not provide the required data, the information is, to the best of my knowledge, true, correct, and
complete in accordance with the statute and rules.
NAME (Please print or type)

TITLE

SIGNATURE

DATE

Subscribed and sworn to before me at the

City of ______________________, State of ___________________

this __________________________day of __________________________, the year ______________

Signature _________________________________________________

My Commission expires ____________________________________

[SEAL]

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