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FORM 4
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)
(First)
1. Title of Security
(Instr. 3)
(State)
(Street)
(City)
OMB APPROVAL
OMB Number:
3235-0287
Expires:
February 28, 2018
Estimated average burden
hours per response
0.5
(Zip)
2. Transaction
Date
(Month/
Day/
Year)
3. Date of Earliest
Transcaction Required
to be Reported
(Month/Day/Year)
4. If Amendment,
Date Original
Filed(Month/Day/Year)
Director
Officer (give
title below)
10% Owner
Other (specify
below)
Amount
(A) or
(D)
Price
5. Amount of
6. Owner- 7. Nature of
Securities
ship
Indirect
Beneficially
Form:
Beneficial
Owned
Direct
OwnerFollowing
(D) or
ship
Reported
Indirect
Transaction (s)
(I)
(Instr. 3 and 4)
(Instr. 4)
(Instr. 4)
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.
(Over)
SEC 1474 (11-11)
FORM 4 (continued)
Date
Exercisable
Code V
(A)
(D)
Expiration
Date
Title
Explanation of Responses:
Date
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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