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The Washington 5 form is an essential document for individuals involved in the reporting of changes in beneficial ownership of securities. This form is used primarily by officers, directors, and significant shareholders of a company to disclose their transactions and holdings in the company's securities. It includes important sections such as the name and address of the reporting person, the issuer's name and trading symbol, and a detailed account of any securities acquired or disposed of during the fiscal year. Each transaction must be accurately reported, including the date, amount, and nature of ownership, whether direct or indirect. Additionally, if the reporting person is no longer subject to Section 16 obligations, they can check a specific box to indicate this change. The form emphasizes the need for electronic submission to the SEC, ensuring compliance with filing requirements. It also highlights the importance of accurate reporting, as intentional misstatements can lead to serious legal consequences. Understanding the Washington 5 form is crucial for anyone involved in the securities market, as it plays a key role in maintaining transparency and accountability within the financial system.

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Potential persons who are to respond to the collection of informa­ tion contained in this form are not required to respond unless the form displays a currently valid OMB control number.

You may not send a completed printout of this form to the SEC to satisfy a filing obligation. submitting the information required by this form to the SEC in electronic format online at

You can only satisfy an SEC filing obligation by https://www.onlineforms.edgarfiling.sec.gov.

FORM 5

Check box if no longer subject to Section 16. Form 4 or Form 5 obli- gations may continue. SEE Instruc- tion 1(b).

Form 3 Holdings Reported Form 4 Transactions Reported

UNITEDSTATESSECURITIESANDEXCHANGECOMMISSION

Washington,D.C.20549

ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF

SECURITIES

OMB APPROVAL

OMB Number:

3235­0362

Expires:

January 31,2014

Estimated average burden

hours per response. . . . . . . 1.0

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

 

(Last)

(First)

 

(Middle)

3.

Statement for Issuer's Fiscal

4. If Amendment, Date

 

 

 

title

 

below)

 

 

 

 

 

 

Year Ended

 

 

 

OriginalFiled

 

 

 

below)

 

 

 

 

 

 

 

 

 

(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 — Non­Derivative Securities Acquired, Disposed of, or Beneficially Owned

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Title of Security

 

 

2. Trans­

2A.Deemed

3.

Trans­

 

4. Securities Acquired (A) or

 

 

 

5. Amount of

6. Owner­

7.

Nature of

 

(Instr. 3)

 

 

action

 

Execu­

 

action

 

Disposed of (D)

 

 

 

 

 

Securities Ben­

ship

 

Indirect

 

 

 

 

Date

 

tion

 

Code

 

(Instr. 3, 4 and 5)

 

 

 

eficially Owned

Form: Di­

 

Beneficial

 

 

 

 

(Month/

 

Date,

 

(Instr. 8)

 

 

 

 

 

 

at end of

rect (D)

 

Ownership

 

 

 

 

Day/

 

if any

 

 

 

 

 

 

 

 

 

 

 

Issuer’s Fiscal

or Indi­

 

(Instr. 4)

 

 

 

 

Year)

(Month/

 

 

 

 

 

 

(A) or

 

 

 

 

Year

rect (I)

 

 

 

 

 

 

 

 

Day/

 

 

 

 

 

 

 

 

 

 

(Instr. 3 and 4)

(Instr. 4)

 

 

 

 

 

 

 

 

 

 

 

Amount

 

(D)

 

Price

 

 

 

 

 

 

 

 

 

 

Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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).

(Over) SEC2270(11­11)

FORM 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-

Security

 

sion or

action

(Instr. 3)

 

Exer-

Date

 

 

cise

(Month/

 

 

Price of

Day/

 

 

Deriva-

Year)

 

 

tive Se-

 

 

 

curity

 

 

 

 

 

 

 

 

 

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

Execetion

tion

 

tive Securities Ac-

 

able and Expi-

 

ing Securities

 

of

 

of De-

ship

Indirect

Date, if

Code

 

quired (A) or Dis-

 

ration Date

 

(Instr. 3 and 4)

 

De-

 

rivative

Form

Benefi-

any

(Instr. 8)

 

posed of (D)

 

(Month/Day/

 

 

 

riva-

 

Securi-

of De-

cial

(Month/

 

 

(Instr. 3, 4, and 5)

 

Year)

 

 

 

 

tive

 

ties Ben-

rivative

Owner-

Day/

 

 

 

 

 

 

 

 

 

 

 

Secu-

 

eficially

Securi-

ship

Year)

 

 

 

 

 

 

 

 

 

 

 

rity

 

Owned

ties:

(Instr. 4)

 

 

 

 

 

 

 

 

 

 

 

 

(Instr. 5)

 

at End of

Direct

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Issuer's

(D) or

 

 

 

 

 

 

Date

 

Expira-

 

 

Amount or

 

 

Fiscal

Indirect

 

 

 

 

 

 

 

 

 

 

 

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

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Document Overview

Fact Name Fact Description
OMB Control Number The Washington 5 form requires a currently valid OMB control number for compliance. Without this number, individuals are not obligated to respond.
Filing Method To satisfy filing obligations, the completed form must be submitted electronically through the SEC's online portal. Physical submissions are not accepted.
SEC Filing Obligations Only electronic submissions at the SEC's designated website can fulfill filing obligations. This emphasizes the importance of using the correct platform.
Form Purpose The Washington 5 form serves as an annual statement of changes in beneficial ownership of securities, ensuring transparency in ownership changes.
Reporting Relationships Individuals must indicate their relationship to the issuer, such as Director, Officer, or 10% Owner, providing clarity on their role.
Amendment Information If the form is an amendment, it must clearly state the original filing date, ensuring proper tracking of changes over time.
Legal Framework The Washington 5 form is governed by the Securities Exchange Act of 1934, which mandates reporting requirements for beneficial ownership.
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