Free Form 3 - Federal


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Pages: 2
File Format: PDF
State: Federal
Category: Government
Author: US SEC
Word Count: 414 Words, 2,776 Characters
Page Size: 792 x 612 pts (letter)
URL

http://sec.gov/about/forms/form3.pdf

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FORM 3
(Print or Type Responses) 1. Name and Address of Reporting Person*

UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 Form 3

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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 2. Date of Event Requiring Statement (Month/Day/Year) (Middle) 3. Issuer Name and Ticker or Trading Symbol

OMB APPROVAL OMB Number: 3235-0104 Expires: February 28, 2011 Estimated average burden hours per response. . . . . . 0.5

(Last)

(First)

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

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

(Street)

Director Officer (give title below) (Zip)

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 ReportingPerson

(City) 1. Title of Security (Instr. 4)

(State)

Table I -- Non-Derivative Securities Beneficially Owned 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership 4. Nature of Indirect Beneficial Ownership Form: Direct (Instr. 5) (D) or Indirect (I) (Instr. 5)

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 5(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 1473 (1-05)

FORM 3 (continued) 1. Title of Derivative Security (Instr. 4)

Table II -- Derivative Securities Beneficially Owned ( e.g., puts, calls, warrants, options, convertible securities) 2. Date Exercisable and Expiration Date
(Month/Day/Year)

3. Title and Amount of Securities Underlying Derivative Security (Instr. 4)

Date Exercisable

Expiration Date

Title

Amount or Number of Shares

4. Conver- 5. Owner- 6. Nature of Indirect ship sion or Beneficial Ownership Form of Exercise (Instr. 5) DerivPrice of ative DeriSecurity: vative Direct Security (D) or Indirect (I) (Instr. 5)

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). 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.

**Signature of Reporting Person

Date

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