Fillable Printable Form 4-United States Securities And Exchange Commission
Fillable Printable Form 4-United States Securities And Exchange Commission
Form 4-United States Securities And Exchange Commission
5. Relationship of Reporting Person(s) to Issuer
1. Name and Address of Reporting Person*
2. Issuer Name and Ticker or Trading Symbol
(Check all applicable)
Director 10% Owner
Officer (give Other (specify
(Last) (First) (Middle)
3. Date of Earliest
4. If Amendment,
title below) below)
Transcaction Required
Date Original
to be Reported
Filed(Month/Day/Year)
(Month/Day/Year)
(Street)
6. Individual or Joint/Group Filing (Check Applicable Line)
__Form filed by One Reporting Person
__Form filed by More than One Reporting Person
(City) (State) (Zip)
Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security 2. Trans- 2A. Deemed 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Owner- 7. Nature of
(Instr. 3) action Execution action or Disposed of (D) Securities ship Indirect
Date Date, if Code (Instr. 3, 4 and 5) Beneficially Form: Beneficial
any (Instr. 8) Owned Direct Owner-
(Month/ Following (D) or ship
(Month/
Day/Year) Reported Indirect
Day/
(A) or Transaction (s) (I)
Year)
Code V Amount (D) Price (Instr. 3 and 4) (Instr. 4) (Instr. 4)
You may not send a completed printout of this form to the SEC to satisfy a filing obligation. You can only satisfy an SEC filing obligation by
submitting the information required by this form to the SEC in electronic format online at https://www.onlineforms.edgarfiling.sec.gov.
(Over)
SEC 1474 (11-11)
FORM 4
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
OMB APPROVAL
OMB Number: 3235-0287
Expires: February 28, 2018
Estimated average burden
hours per response 0.5
Check this box if no longer
subject to Section 16. Form 4 or
Form 5 obligations may continue.
See Instruction 1(b).
(Print or Type Responses)
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
information contained in this form are not required to respond
unless the form displays a currently valid OMB control number.
FORM 4 (continued) Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned
( e.g., puts, calls, warrants, options, convertible securities)
1.
Title of Derivative
Security
(Instr. 3)
2. Conver-
sion or
Exercise
Price of
Deri-
vative
Security
3. Trans-
action
Date
(Month/
Day/
Year)
3A.Deemed
Execution
Date, if
any
(Month/
Day/
Year)
4. Trans-
action
Code
(Instr. 8)
5. Number of Deriv-
ative Securities Ac-
quired (A) or Dis-
posed of (D)
(Instr. 3, 4, and 5)
6. Date Exer-
cisable and
Expiration
Date
(Month/Day/
Year)
7. Title and Amount of
Underlying Securities
(Instr. 3 and 4)
8. Price
of
Deriv-
ative
Secur-
ity
(Instr.
5)
9. Number
of deriv-
ative
Secur-
ities
Bene-
ficially
Owned
follow-
ing
Re-
ported
Transac-
tion
(s)(Instr.
4)
10.Owner-
ship
Form of
Deriv-
ative
Security:
Direct
(D) or
Indirect
(I)
(Instr. 4)
11. Nature
of
Indirect
Benefi-
cial
Owner-
ship
(Instr. 4)
Date Expira-
Exer- tion
cisable Date
Amount or
Title Number of
Shares
Code V (A) (D)
Explanation of Responses:
**Signature of Reporting Person Date** 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.
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