Form SEC 2270 SEC 2270 Form 5

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

FORM 5

ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF
SECURITIES

Check box if no longer subject to
Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
Form 3 Holdings Reported
Form 4 Transactions Reported

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility
Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940

1. Name and Address of Reporting Person*

(Last)

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2. Issuer Name and Ticker or Trading Symbol

(First)

(Middle)

3. Statement for Issuer's Fiscal
Year Ended
(Month//Day/Year)

5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
_____ 10% Owner
_____ Officer (give
_____ Other (specify
title
below)
below)

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

____________________________
6. Individual or Joint/Group Reporting

(Street)

(check applicable line)

_____ Form Filed by One Reporting Person
_____ Form Filed by More than One Reporting Person

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

(State)

(Zip)

Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

2. Transaction
Date
(Month/
Day/
Year)

2A.Deemed 3. Trans- 4. Securities Acquired (A) or
action
Disposed of (D)
ExecuCode
(Instr. 3, 4 and 5)
tion
(Instr. 8)
Date,
if any
(Month/
(A) or
Day/
Amount
(D)
Year)

6. Owner- 7. Nature of
5. Amount of
ship
Indirect
Securities BenForm: DiBeneficial
eficially Owned
rect (D)
Ownership
at end of
(Instr. 4)
or IndiIssuer’s Fiscal
rect (I)
Year
Price

(Instr. 3 and 4)

(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 informa-

tion contained in this form are not required to respond unless the
form displays a currently valid OMB control number.

(Over)
SEC 2270 (1-05)

FORM 5 (continued)

Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)

1. Title of Derivative 2. Conver- 3. Trans- 3A.Deemed 4. Transac- 5. Number of Deriva- 6. Date Exercis- 7. Title and Amount of Underly- 8. Price 9.
Security
sion or
tion
tive Securities Acable and Expiing Securities
of
action Execetion
(Instr. 3)
(Instr. 3 and 4)
ExerDate, if
Code
quired (A) or Disration Date
DeDate
(Month/
(Instr. 8)
(Month/Day/
cise
any
posed of (D)
rivaYear)
(Instr. 3, 4, and 5)
Price of Day/
(Month/
tive
Year) Day/
DerivaSecutive SeYear)
rity
(Instr. 5)
curity
Date
Exercisable
(A)

Expiration
Date

Title

Amount or
Number of
Shares

(D)

Number 10. Owner- 11. Nature of
of Deship
Indirect
rivative
Form
BenefiSecuriof Decial
ties Benrivative
Ownereficially
Securiship
(Instr. 4)
Owned
ties:
at End of
Direct
Issuer's
(D) or
Fiscal
Indirect
Year
(I)
(Instr.
4)

(Instr. 4)

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 provided 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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