7. Individual or Joint/Group
Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security
(Instr. 4)
2. Amount of Securities Beneficially Owned
(Instr.4)
3. Ownership Form:
Direct (D)
or
Indirect (I)
(Instr. 5)
4. Nature of Indirect Beneficial Ownership
(Instr. 5)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security
(Instr. 4)
2. Date Exercisable(DE) and
Expiration Date(ED)
(Month/Day/Year)
DE / ED
3. Title and Amount of
Underlying Securities
(Instr. 4)
Title / Amount or Number of Shares
4. Conver-
sion or
Exercise
Price of
Deri-
vative
Security
5. Owner-
ship
Form of
Deriv-
ative
Security:
Direct (D)
or
Indirect (I)
(Instr.5)
6. Nature of
Indirect
Beneficial
Ownership
(Instr.5)
/
/
$
Explanation of Responses:
By:
/s/
** Signature of Reporting Person Date
SEC 1473 (07/02)
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 5(b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
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 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.