Form 5 - Securex Filings printable pdf download

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UNITED STATES SECURITIES AND EXCHANGE COMMISSION

FORM 5

OMB APPROVAL

Washington, D.C. 20549

OMB Number:

3235-0362

Expires:

January 31,2014

Check box if no longer subject to

Section 16. Form 4 or Form 5 obli

ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF

Estimated average burden

gations may continue. See Instruc

hours per response. . . . . . .

1.0

tion 1(b).

SECURITIES

Form 3 Holdings Reported

Form 4 Transactions Reported

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)

3. Statement for Issuer's Fiscal

4. If Amendment, Date

(Last)

(First)

(Middle)

below)

Year Ended

Original Filed

(Month//Day/Year)

(Month/Day/Year)

____________________________

6. Individual or Joint/Group Reporting

(Street)

(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-

3. Trans-

4. Securities Acquired (A) or

5. Amount of

6. Owner-

7. Nature of

2A.Deemed

(Instr. 3)

action

Disposed of (D)

Securities Ben-

ship

Indirect

Execu-

Date

Code

(Instr. 3, 4 and 5)

eficially Owned

Form: Di-

Beneficial

tion

(Month/

(Instr. 8)

at end of

rect (D)

Ownership

Date,

Day/

Issuer’s Fiscal

or Indi-

(Instr. 4)

if any

Year)

Year

rect (I)

(Month/

(A) or

(Instr. 3 and 4)

(Instr. 4)

Day/

Amount

(D)

Price

Year)

Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.

(Over)

* 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 - Securex Filings

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