FORM 4 |
STATEMENT OF |
CHANGES IN BENEFICIAL OWNERSHIP |
[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
1. Name and Address of Reporting Person*
(Last) |
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(First) |
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(Middle) |
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(Street) |
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(City) |
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(State) |
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(Zip) |
2. Issuer Name and Ticker or Trading Symbol
(Issuer Name) |
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(Ticker or Trading Symbol) |
3. I.R.S. Identification Number of Reporting Person, if an entity (voluntary)
(I.D. Number) |
4. Statement for Month/Day/Year
(Month/Day) |
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(Year) |
5. If Amendment, Date of Original (Month/Day/Year)
(Month/Day) |
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(Year) |
6. Relationship of Reporting Person(s) to Issuer (Check all applicable)
X
(Director) |
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(Officer, give title below) |
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(10% Owner) |
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(Other, specify below) |
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7. Individual or Joint/Group Filing (Check Applicable Line)
X
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
1.Title of Security |
2.Transaction Date |
2A. Deemed Execution Date, if any (Month/ |
3. Transaction Code |
4. Securities Acquired (A) or Disposed of ( D) |
5. Amount of Securities Beneficially Owned Following Reported Transaction(s) |
6. Owner-ship Form: Direct (D) or Indirect (I) |
7. Nature of Indirect Beneficial Ownership |
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Code |
V |
Amount |
(A) or (D) |
Price |
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Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned |
(e.g., puts, calls, warrants, options, convertible securities) |
1. Title of Derivative Security |
2. Conversion or Exercise Price of Derivative Security |
3. Transaction Date (Month/Day/ |
3A. Deemed Execution Date, if any (Month/Day/ |
4. Transaction Code (Instr.8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Securities: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code |
V |
(A) |
(D) |
Date |
Expiration |
Title |
Amount or Number of Shares |
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Explanation of Responses: |
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**Signature of Reporting Person |
Date |
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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).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a.).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.