-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, P5f7LdcZBXUwkUfrYxEkZLCXjgHJgKhlV3s0P1Up9w2IFM9JlxQmOaRzfXe9Mlcw UhwgxAc6EBEKmamE7TqsyA== 0000950129-01-501242.txt : 20010611 0000950129-01-501242.hdr.sgml : 20010611 ACCESSION NUMBER: 0000950129-01-501242 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20010501 FILED AS OF DATE: 20010608 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: U S PHYSICAL THERAPY INC /NV CENTRAL INDEX KEY: 0000885978 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-HEALTH SERVICES [8000] IRS NUMBER: 760364866 STATE OF INCORPORATION: NV FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: SEC FILE NUMBER: 033-47019 FILM NUMBER: 1656563 BUSINESS ADDRESS: STREET 1: 3040 POST OAK BLVD STE 222 CITY: HOUSTON STATE: TX ZIP: 77056 BUSINESS PHONE: 7132977000 MAIL ADDRESS: STREET 1: 3040 POST OAK BLVD STREET 2: SUITE 222 CITY: HOUSTON STATE: TX ZIP: 77056 COMPANY DATA: COMPANY CONFORMED NAME: MAURAN RICHARD C W CENTRAL INDEX KEY: 0001036232 STANDARD INDUSTRIAL CLASSIFICATION: [] OWNER FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: FRENCH FRANGRANCES INC STREET 2: 15595 NW 15 AVE CITY: MIAMI STATE: FL ZIP: 33169 MAIL ADDRESS: STREET 1: FRENCH FRANGRANCES INC STREET 2: 15595 NW 15 AVE CITY: MIAMI STATE: FL ZIP: 33169 4 1 h88244e4.txt RICHARD C.W. MARURAN FOR USPH 1 - ------ -------------------------- FORM 4 OMB APPROVAL - ------ -------------------------- [ ] CHECK THIS BOX IF NO OMB Number: 3235-0287 LONGER SUBJECT TO Expires: December 31, 2001 SECTION 16. FORM 4 Estimated average burden OR FORM 5 OBLIGATIONS hours per response.... 0.5 MAY CONTINUE. SEE -------------------------- INSTRUCTION 1(b). UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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(f) of the Investment Company Act of 1940 (Print or Type Responses) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) MAURAN RICHARD C.W. U.S. PHYSICAL THERAPY, INC. (USPH) to Issuer (Check all applicable) - --------------------------------------------- ---------------------------------------------- Director XX 10% Owner (Last) (First) (Middle) 3. IRS Identification 4. Statement for ---- --- Number of Reporting Month/Year Officer (give Other (Specify 31 BURTON COURT, FRANKLINS ROW Person, if an entity MAY 2001 ---- title --- below) - --------------------------------------------- (voluntary) ------------------- below) (Street) 5. If Amendment, LONDON, SW3 ENGLAND Date of Original - --------------------------------------------- -------------------- (Month/Year) -------------------------------- (City) (State) (Zip) 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 ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature (Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In- Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct (Instr. 8) End of Month Direct Benefi- (Month/ (Instr. 3 and 4) (D) or cial Day/ ------------------------------------ Indirect Owner- Year) Code V Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 100 D $19.50 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 3,600 D $19.73 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 9,100 D $19.74 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 3,900 D $20.28 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 2,500 D $20.39 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 400 D $20.50 0 D - ------------------------------------------------------------------------------------------------------------------------------------ Page 1 of 6 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). SEC 1474 (3-99) POTENTIAL PERSONS WHO ARE TO RESPOND TO THE COLLECTIONS OF INFORMATION CONTAINED IN THIS FORM ARE NOT REQUIRED TO RESPOND UNLESS THE FORM DISPLAYS A CURRENTLY VALID OMB CONTROL NUMBER.
2 - ------ -------------------------- FORM 4 OMB APPROVAL - ------ -------------------------- [ ] CHECK THIS BOX IF NO OMB Number: 3235-0287 LONGER SUBJECT TO Expires: December 31, 2001 SECTION 16. FORM 4 Estimated average burden OR FORM 5 OBLIGATIONS hours per response.... 0.5 MAY CONTINUE. SEE -------------------------- INSTRUCTION 1(b). UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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(f) of the Investment Company Act of 1940 (Print or Type Responses) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) MAURAN RICHARD C.W. U.S. PHYSICAL THERAPY, INC. (USPH) to Issuer (Check all applicable) - --------------------------------------------- ---------------------------------------------- Director XX 10% Owner (Last) (First) (Middle) 3. IRS Identification 4. Statement for ---- --- Number of Reporting Month/Year Officer (give Other (Specify 31 BURTON COURT, FRANKLINS ROW Person, if an entity MAY 2001 ---- title --- below) - --------------------------------------------- (voluntary) ------------------- below) (Street) 5. If Amendment, LONDON, SW3 ENGLAND Date of Original - --------------------------------------------- -------------------- (Month/Year) -------------------------------- (City) (State) (Zip) 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 ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature (Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In- Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct (Instr. 8) End of Month Direct Benefi- (Month/ (Instr. 3 and 4) (D) or cial Day/ ------------------------------------ Indirect Owner- Year) Code V Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 1,000 D $20.58 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 300 D $20.59 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 300 D $20.64 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 500 D $20.72 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 300 D $20.73 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/1/01 S 800 D $20.74 0 D - ------------------------------------------------------------------------------------------------------------------------------------ Page 2 of 6 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). SEC 1474 (3-99) POTENTIAL PERSONS WHO ARE TO RESPOND TO THE COLLECTIONS OF INFORMATION CONTAINED IN THIS FORM ARE NOT REQUIRED TO RESPOND UNLESS THE FORM DISPLAYS A CURRENTLY VALID OMB CONTROL NUMBER.
3 - ------ -------------------------- FORM 4 OMB APPROVAL - ------ -------------------------- [ ] CHECK THIS BOX IF NO OMB Number: 3235-0287 LONGER SUBJECT TO Expires: December 31, 2001 SECTION 16. FORM 4 Estimated average burden OR FORM 5 OBLIGATIONS hours per response.... 0.5 MAY CONTINUE. SEE -------------------------- INSTRUCTION 1(b). UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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(f) of the Investment Company Act of 1940 (Print or Type Responses) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) MAURAN RICHARD C.W. U.S. PHYSICAL THERAPY, INC. (USPH) to Issuer (Check all applicable) - --------------------------------------------- ---------------------------------------------- Director XX 10% Owner (Last) (First) (Middle) 3. IRS Identification 4. Statement for ---- --- Number of Reporting Month/Year Officer (give Other (Specify 31 BURTON COURT, FRANKLINS ROW Person, if an entity MAY 2001 ---- title --- below) - --------------------------------------------- (voluntary) ------------------- below) (Street) 5. If Amendment, LONDON, SW3 ENGLAND Date of Original - --------------------------------------------- -------------------- (Month/Year) -------------------------------- (City) (State) (Zip) 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 ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature (Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In- Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct (Instr. 8) End of Month Direct Benefi- (Month/ (Instr. 3 and 4) (D) or cial Day/ ------------------------------------ Indirect Owner- Year) Code V Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/7/01 S 20,000 D $26.10 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/7/01 S 20,000 D $25.7848 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/8/01 S 20,000 D $25.8512 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/8/01 S 25,000 D $26.65 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/8/01 S 19,800 D $26.5268 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/8/01 S 20,000 D $25.75 0 D - ------------------------------------------------------------------------------------------------------------------------------------ Page 3 of 6 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). SEC 1474 (3-99) POTENTIAL PERSONS WHO ARE TO RESPOND TO THE COLLECTIONS OF INFORMATION CONTAINED IN THIS FORM ARE NOT REQUIRED TO RESPOND UNLESS THE FORM DISPLAYS A CURRENTLY VALID OMB CONTROL NUMBER.
4 - ------ -------------------------- FORM 4 OMB APPROVAL - ------ -------------------------- [ ] CHECK THIS BOX IF NO OMB Number: 3235-0287 LONGER SUBJECT TO Expires: December 31, 2001 SECTION 16. FORM 4 Estimated average burden OR FORM 5 OBLIGATIONS hours per response.... 0.5 MAY CONTINUE. SEE -------------------------- INSTRUCTION 1(b). UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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(f) of the Investment Company Act of 1940 (Print or Type Responses) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) MAURAN RICHARD C.W. U.S. PHYSICAL THERAPY, INC. (USPH) to Issuer (Check all applicable) - --------------------------------------------- ---------------------------------------------- Director XX 10% Owner (Last) (First) (Middle) 3. IRS Identification 4. Statement for ---- --- Number of Reporting Month/Year Officer (give Other (Specify 31 BURTON COURT, FRANKLINS ROW Person, if an entity MAY 2001 ---- title --- below) - --------------------------------------------- (voluntary) ------------------- below) (Street) 5. If Amendment, LONDON, SW3 ENGLAND Date of Original - --------------------------------------------- -------------------- (Month/Year) -------------------------------- (City) (State) (Zip) 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 ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature (Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In- Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct (Instr. 8) End of Month Direct Benefi- (Month/ (Instr. 3 and 4) (D) or cial Day/ ------------------------------------ Indirect Owner- Year) Code V Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/8/01 S 20,000 D $25.862 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/9/01 S 1,300 D $26.51 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/9/01 S 10,500 D $26.50 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/9/01 S 1,600 D $26.50 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/10/01 S 2,400 D $26.5104 0 D - ------------------------------------------------------------------------------------------------------------------------------------ Page 4 of 6 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). SEC 1474 (3-99) POTENTIAL PERSONS WHO ARE TO RESPOND TO THE COLLECTIONS OF INFORMATION CONTAINED IN THIS FORM ARE NOT REQUIRED TO RESPOND UNLESS THE FORM DISPLAYS A CURRENTLY VALID OMB CONTROL NUMBER.
5 - ------ -------------------------- FORM 4 OMB APPROVAL - ------ -------------------------- [ ] CHECK THIS BOX IF NO OMB Number: 3235-0287 LONGER SUBJECT TO Expires: December 31, 2001 SECTION 16. FORM 4 Estimated average burden OR FORM 5 OBLIGATIONS hours per response.... 0.5 MAY CONTINUE. SEE -------------------------- INSTRUCTION 1(b). UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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(f) of the Investment Company Act of 1940 (Print or Type Responses) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) MAURAN RICHARD C.W. U.S. PHYSICAL THERAPY, INC. (USPH) to Issuer (Check all applicable) - --------------------------------------------- ---------------------------------------------- Director XX 10% Owner (Last) (First) (Middle) 3. IRS Identification 4. Statement for ---- --- Number of Reporting Month/Year Officer (give Other (Specify 31 BURTON COURT, FRANKLINS ROW Person, if an entity MAY 2001 ---- title --- below) - --------------------------------------------- (voluntary) ------------------- below) (Street) 5. If Amendment, LONDON, SW3 ENGLAND Date of Original - --------------------------------------------- -------------------- (Month/Year) -------------------------------- (City) (State) (Zip) 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 ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature (Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In- Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct (Instr. 8) End of Month Direct Benefi- (Month/ (Instr. 3 and 4) (D) or cial Day/ ------------------------------------ Indirect Owner- Year) Code V Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/14/01 S 20,000 D $26.50 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/14/01 S 12,900 D $26.6795 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/15/01 S 6,500 D $26.50 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/17/01 S 1,000 D $31.217 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/22/01 S 29,000 D $31.0138 0 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 5/29/01 S 30,000 A $26.02 0 D - ------------------------------------------------------------------------------------------------------------------------------------ Page 5 of 6 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). SEC 1474 (3-99) POTENTIAL PERSONS WHO ARE TO RESPOND TO THE COLLECTIONS OF INFORMATION CONTAINED IN THIS FORM ARE NOT REQUIRED TO RESPOND UNLESS THE FORM DISPLAYS A CURRENTLY VALID OMB CONTROL NUMBER.
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FORM 4 (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- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price Security sion or action action Derivative cisable and of Underlying of (Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv- Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative Deriv- Day/ Disposed of (D) (Month/Day/ Secur- ative Year) (Instr. 3, 4, Year) ity Security and 5) (Instr. 5) ----------------------------------- Date Expira- Amount or -------------------------- Exer- tion Title Number of Code V (A) (D) cisable Date Shares - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ 9. Number of 10. Ownership 11. Nature of Derivative Form of Indirect Securities Derivative Beneficial Beneficially Security: Ownership Owned at End Direct (D) (Instr. 4) of Month or Indirect (I) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- Explanation of Responses: /s/ RICHARD C.W. MAURAN 6/8/01 **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. ----------------------------- ---------- See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). **Signature of Reporting Person Date RICHARD C.W. MAURAN Page 6 of 6 Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. SEC 1474 (3-99) 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.
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