Fillable Printable Form 5
Fillable Printable Form 5
Form 5
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 5
Check box if no longer subject to
Section 16. Form 4 or Form 5 obli-
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF
gations may continue. See Instruc-
tion 1(b).
SECURITIES
Form 3 Holdings Reported
Form 4 Transactions Reported
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.
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1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director _____ 10% Owner
_____ Officer (give _____ Other (specify
title below)
below)
____________________________
(Last) (First) (Middle)
3. Statement for Issuer's Fiscal
Year Ended
(Month//Day/Year)
4. If Amendment, Date
Original Filed
(Month/Day/Year)
6. Individual or Joint/Group Reporting
(check applicable line)
_____ Form Filed by One Reporting Person
_____ Form Filed by More than One Reporting Person
(Street)
(City) (State) (Zip)
Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security
(Instr. 3)
2. Trans-
action
Date
(Month/
Day/
Year)
2A.Deemed
Execu-
tion
Date,
if any
(Month/
Day/
Year)
3. Trans-
action
Code
(Instr. 8)
4. Securities Acquired (A) or
Disposed of (D)
(Instr. 3, 4 and 5)
5. Amount of
Securities Ben-
eficially Owned
at end of
Issuer’s Fiscal
Year
(Instr. 3 and 4)
6. Owner-
ship
Form: Di-
rect (D)
or Indi-
rect (I)
(Instr. 4)
7. Nature of
Indirect
Beneficial
Ownership
(Instr. 4)
Amount
(A) or
(D) Price
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-
SEC 2270 (11-11)
tion contained in this form are not required to respond unless the
form displays a currently valid OMB control number.
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
Security
(Instr. 3)
2. Conver-
sion or
Exer-
cise
Price of
Deriva-
tive Se-
curity
3. Trans-
action
Date
(Month/
Day/
Year)
3A. Deemed
Execetion
Date, if
any
(Month/
Day/
Year)
4. Transac-
tion
Code
(Instr. 8)
5. Number of Deriva-
tive Securities Ac-
quired (A) or Dis-
posed of (D)
(Instr. 3, 4, and 5)
6. Date Exercis-
able and Expi-
ration Date
(Month/Day/
Year)
7. Title and Amount of Underly-
ing Securities
(Instr. 3 and 4)
8. Price
of
De-
riva-
tive
Secu-
rity
(Instr. 5)
9. Number
of De-
rivative
Securi-
ties Ben-
eficially
Owned
at End of
Issuer's
Fiscal
Year
(Instr.
4)
10. Owner-
ship
Form
of De-
rivative
Securi-
ties:
Direct
(D) or
Indirect
(I)
(Instr. 4)
11. Nature of
Indirect
Benefi-
cial
Owner-
ship
(Instr. 4)
Date
Exer-
cisable
Expira-
tion
Date Title
Amount or
Number of
Shares
(A)
(D)
Explanation of Responses:
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations. ** Signature of Reporting Person Date
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 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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