FORM 5
OMB APPROVAL
Washington, D.C. 20549
Check this 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 Required
OMB Number:
ANNUAL STATEMENT OF CHANGES IN 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. Issuer Name and Ticker or Trading Symbol
1. Name and Address of Reporting Person*
(“
(Last)
3235-0362
Estimated average burden
hours per response………………………..1.0
(First)
(Middle) 3. Statement for Issuer’s Fiscal
Year Ended
(Month/Day/Year)
4. If Amendment, Date
Original Filed
(Month/Day/Year)
(Street)***
”)
5. Relationship of Reporting Person(s) to Issuer**
(Check all applicable)
Director
10% Owner
Officer (give title
below)
Other
(specify below)
6 Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
(City)
(State)
(Zip)
Form filed by More than One Reporting Person
NOTE:
* The Reporting Person’s name is only collected for proofing purposes, the EDGAR system will replace any name provided on this form with the name that is on record connected to the Reporting
Person’s EDGAR Profile provided by the CIK#. The address is optional. If you do not provide an address the SEC will use the address on record with the SEC using the reporting owner’s CIK.
** To place an X for all that apply click on the checkboxes. Officer Title has a maximum of 30 characters.
*** If you do not provide an address the EDGAR system will use the address on record from the EDGAR Profile connected to the Reporting Person’s CIK #.
Reporting Person
(Reporting Person CIK)
Mandatory
(Reporting Person CCC
Mandatory
Issuer CIK and Trading Symbol
(Issuer CIK)
Mandatory
(Issuer Ticker code)
Mandatory if not entered in Section 2 above.
Form 5 Worksheet created by
Securex EDGAR Filing Service Bureau
877-SEC-FILE (Option 1)
www.secfile.com l [email protected]
© 2011 Securex Filings LLC all rights reserved on additional notes, instructions, and information. Based on official SEC Form.
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of
Security
2. Transaction Date
(M/D/Y)
2A. Deemed
Execution
Date, if any
(Instr. 1)
(M/D/Y)
3. Transaction Code (Instr. 2)
Does this
transaction Is this a Form 5
Trans- involve an
transaction
action
Equity
being reported
early? (enter Y
Code
Swap
(enter Y or
or N only)
N only)
5. Amount of Securities
Beneficially Owned at end 6. Ownership 7. Nature of Indirect
Form: D
Beneficial Ownership
of Issuer’s Fiscal Year
(Direct) or
(Instr. 6)
(Instr. 3)
A
I (Indirect)
(Acquired)
(Instr. 5)
or D
Number of
(Disposed) Dollars* OR
Securities
4. Securities (Instr. 3 and 4)
Number of
Securities
Price*
sf
The “TAB” key moves the insertion point from cell to cell and will add rows when entered in the last cell. The maximum number of rows allowable by the SEC for transaction/holdings is 30.
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* The SEC will only report dollar values to one decimal point when the second digit is zero (i.e. 10.20 will be reported as 10.2)
Instructions (See Template Notes and Information for an y further inquiries):
1. If no value is provided a footnote is required.
2. A transaction code is required; refer to Template Instructions, Transaction Codes List.
3. The value entered should state the face amount of debt securities in U.S. Dollars OR the number of equity securities, whichever is appropriate. You cannot provide a value for both. Zero is
allowed. If no value is provided a footnote is required.
4. Requires the exercise or conversion price of derivative security to be reported in dollars. A conversion or exercise price that is not dollar-denominated should be entered as "0" (zero) in Column
2 with a footnote explaining that the security converts to common stock on a one-for-one basis.
5. If “I” (Indirect) is entered, then "Nature of Ownership" (next column) must be provided. If “D”, then "Nature of Ownership” must be blank.
6.
Required IF “I” (Indirect) is entered in the previous column. There is a 100 character limit. You must enter a description here if you wish to enter a footnote, such as See Footnote.
Form 5 Worksheet created by
Securex EDGAR Filing Service Bureau
877-SEC-FILE (Option 1)
www.secfile.com l [email protected]
© 2011 Securex Filings LLC all rights reserved on additional notes, instructions, and information. Based on official SEC Form.
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1.Title of Derivative 2. Conversion 3.TransSecurity
or Exercise
action
Price of
Date
Derivative
(M/D/Y)
Security
(Instr. 2)
(Instr. 1)
3A.Deemed 4. Transaction Code (Instr. 3) 5. Number of Derivative
6. Date Exercisable
7. Title and Amount of
8. Price of 9. Number of
10.Owner- 11. Nature of
Execution
Securities Acquired (A)
and Expiration Date
Securities Underlying
Derivative derivative
ship Form Indirect Beneficial
Date,
or Disposed of (D)
(Instr. 2)
Securities
Security Securities
of
Ownership (Instr. 7)
if any
(Instr. 4)
(Inst. 5)
(Instr. 1) Beneficially Owned Derivative
(M/D/Y)
at End of Issuer’s Securities:
Dollar Value*
Is this a
Fiscal Year
D (Direct)
Dollar Value*
OR
Does this
Form 5
(Instr. 5)
or
OR
A
transaction
Number of
transaction
I (Indirect)
Number of
involve an
Acquired
Date
Expiration
Securities
being
(Instr. 6)
Securities
Code
equity
or
Exercisable
Date
Title
reported Number
swap?
(M/D/Y)
(M/D/Y)
D
early?
Value Number of
of
OR
(enter Y or
(enter Y or Secur- Value Disposed
Value Number
OR Securities
N only)
of
N only)
OR Securities
ities
The “TAB” key moves the insertion point from cell to cell and will add rows when entered in the last cell. The maximum number of rows allowable by the SEC for transaction/holdings is 30.
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* The SEC will only report dollar values to one decimal point when the second digit is zero (i.e. 10.20 will be reported as 10.2)
Instructions (See Template Notes and Information for an y further i nquiries):
1. Requires the exercise or conversion price of derivative security to be reported in dollars. A conversion or exercise price that is not dollar-denominated should be entered as "0" (zero) in Column
2 with a footnote explaining that the security converts to common stock on a one-for-one basis.
2. If no value is provided a footnote is required.
3. A transaction code is required; refer to Template Instructions, Transaction Codes List.
4. The value entered should state the face amount of debt securities in U.S. Dollars OR the number of equity securities, whichever is appropriate. You cannot provide a value for both. A value
is required and a footnote is not allowed.
5. The value entered should state the face amount of debt securities in U.S. Dollars OR the number of equity securities, whichever is appropriate. You cannot provide a value for both. Zero is
allowed. If no value is provided a footnote is required.
6. If “I” (Indirect) is entered, then "Nature of Ownership" (next column) must be provided. If “D”, then "Nature of Ownership” must be blank.
7. Required IF “I” (Indirect) is entered in the previous column. There is a 100 character limit. You must enter a description here if you wish to enter a footnote, such as See Footnote.
Form 5 Worksheet created by
Securex EDGAR Filing Service Bureau
877-SEC-FILE (Option 1)
www.secfile.com l [email protected]
© 2011 Securex Filings LLC all rights reserved on additional notes, instructions, and information. Based on official SEC Form.
Explanation of Responses (Footnotes):
Footnote
number
Footnote text
Note:




If no value is provided a footnote is required.
A single footnote cannot exceed 1,000 characters including spaces. If more space is required, you may use two footnotes.
Footnotes are not allowed for the Table II, Item 5 Acquired/Disposed Code field of Forms 4, 4/A, 5 or 5/A. ++
Foot note description is required for Table I, Item 7 and Table II, Item 11 Nature of Indirect Ownership – you cannot leave these descriptions blank.
Signature
Date:
/s/
(Name of Reporting Person or Name of Individual with signing authority (Power of
Attorney) for the Reporting Person)
(MM/DD/YYYY)
Remarks (maximum of 1900 characters including spaces):
Exhibit Numbering:
Exhibit 24 – Power of Attorney, Exhibit 99 – Additional Exhibits.
Form 5 Worksheet created by
Securex EDGAR Filing Service Bureau
877-SEC-FILE (Option 1)
www.secfile.com l [email protected]
© 2011 Securex Filings LLC all rights reserved on additional notes, instructions, and information. Based on official SEC Form.
Form 5 Template Notes and Information

The SEC may auto-populate some fields once the filing is submitted.

Link to SEC Q&A: http://www.sec.gov/divisions/corpfin/sec16faq.htm

The telephone number for the SEC Office of EDGAR & Information Analysis is 202-551-3610; they can assist you with any question regarding the
Section 16 requirements.

For a complete list and general instructions on completing a Form 4 follow the link to the SEC at http://www.sec.gov/about/forms/form4data.pdf
1.
Title of Security (Table I & II, Item 1) has a maximum 60 characters.
2.
Table I, Items 2 and 2A, and Table II, Items 3 and 3A, Transaction Dates: You may insert only a footnote, or date and footnote,
whichever is applicable.
3.
Table I, Item 3 and Table II, Item 4, Equity Swap (Yes):
If Y is entered for Equity Swap, the SEC will add a “/K” after the code in the “Transaction Code” column, you will see it in the
PDF proof.
If Y is entered for Early Form 5 Transaction, the SEC will enter the letter V (for voluntarily reporting early) in the column with
the column heading "V", you will see it in the PDF proof.
4.
Table I, Item 5, the conversion or exercise price of the derivative security has a maximum of 20 digits. If no value is provided, a
footnote is required.
5.
Table II, Item 5, the conversion or exercise price of the derivative security has a maximum of 20 digits. A footnote is not
allowed, an amount must be entered for this field.
6.
Table I, Item 5 and Table II, Item 7 and Item 9, Dollar Value OR Number of Securities has a maximum of 20 digits. You must
provide either a $ amount OR a number of securities. The value entered should state the face amount of debt securities OR
the number of equity securities, whichever is appropriate. You cannot provide a value for both. Zero is allowed and if no value
is provided, a footnote is required.
Transaction Code List
General Transaction Codes
P Open market or private purchase of non-derivative or derivative security
S Open market or private sale of non-derivative or derivative security
V Transaction voluntarily reported earlier than required
Rule 16b-3 Transaction Codes
A Grant, award or other acquisition pursuant to Rule 16b-3(d)
D Disposition to the issuer of issuer equity securities pursuant to Rule 16b-3(e)
F Payment of exercise price or tax liability by delivering or withholding securities incident to the receipt, exercise or vesting of a
security issued in accordance with Rule 16b-3
I
Discretionary transaction in accordance with Rule 16b-3(f) resulting in acquisition or disposition of issuer securities
M Exercise or conversion of derivative security exempted pursuant to Rule 16b-3
Derivative Securities Codes (Except for transactions exempted pursuant to Rule 16b-3)
C Conversion of derivative security
E Expiration of short derivative position
H Expiration (or cancellation) of long derivative position with value received
O Expiration of out-of-the-money derivative security
X Exercise of in-the-money or at-the-money derivative security
Other Section 16(b) Exempt Transaction and Small Acquisition Codes (except for Rule 16b-3 codes above)
G Bona fide gift
L Small acquisition under Rule 16a-6
W Acquisition or disposition by will or the laws of descent and distribution
Z Deposit into or withdrawal from voting trust
Other Transaction Codes
© 2011 Securex Filings LLC all rights reserved on additional notes, instructions, and information. Based on official SEC Form.
J
K
U
Other acquisition or disposition (describe transaction)
Transaction in equity or instrument with similar characteristics
Disposition pursuant to a tender of shares in a change of control transaction
© 2011 Securex Filings LLC all rights reserved on additional notes, instructions, and information. Based on official SEC Form.