Form 5 - Securex Filings Page 2
ADVERTISEMENT
1
2FORM 5 (continued)
Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative
2. Conver
3. Trans
3A.Deemed
4. Transac
5. Number of Deriva
6. Date Exercis
7. Title and Amount of Underly
8. Price
9. Number
10. Owner
11. Nature of
Security
sion or
action
Execetion
tion
tive Securities Ac
able and Expi
ing Securities
of
of De
ship
Indirect
(Instr. 3)
Exer
Date
Date, if
Code
quired (A) or Dis
ration Date
(Instr. 3 and 4)
De
rivative
Form
Benefi
cise
any
posed of (D)
riva
Securi
of De
cial
(Month/
(Instr. 8)
(Month/Day/
Price of
Day/
(Month/
(Instr. 3, 4, and 5)
Year)
tive
ties Ben
rivative
Owner
Deriva
Year)
Day/
Secu
eficially
Securi
ship
tive Se
Year)
rity
Owned
ties:
(Instr. 4)
curity
at End of
Direct
(Instr. 5)
Issuer's
(D) or
Fiscal
Indirect
Date
Expira
Amount or
Year
(I)
Exer
tion
Number of
(Instr.
(Instr. 4)
cisable
Date
Title
Shares
4)
(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.
Page 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 8868 - Application For Extension Of Time To File An Exempt Organization Return - Filing Example (with Form 990 As Filed Return)
Financial
Form 3586 (e-file) - California Payment Voucher For Corporations And Exempt Organizations E-filed Returns - 2015
Financial
Related Categories
Parent category: Legal