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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT 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 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
Persons who 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. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
GOODMAN CHARLES H 222 N LASALLE STREET STE 200 CHICAGO, IL 60601 |
X |
/s/ Charles H. Goodman | 01/05/2004 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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). |
(1) | Adjustment to the number of shares of Performance Restricted Stock at the end of the performance period ending 12/31/2004 |
(2) | Owned by First National Bank of Chicago, as custodian, for the benefit of the Reporting Person |
(3) | Owned by a partnership, The Crown Fund, of which the Reporting Person is a partner |
(4) | Onwed by a trust, Charles Grandchildren Trust, of which the Reporting Person is a co-trustee and his grandchildren are beneficiaries |
(5) | Owned by a partnership, Crown Fund II, of which the Reporting Person is a partner |
(6) | Owned by a trust, Charles GD 03 Trust, of which the Reporting Person is the trustee and a beneficiary |
(7) | Owned by a trust, Charles Pharma Trust, of which the Reporting Person is the trustee and a beneficiary |
Remarks: The Reporting Person disclaims beneficial ownership of the shares described in footnotes 2, 3, 4, 5, 6, and 7, except to the extent of his beneficial ownership interest in the entities that own these shares. |