FDIC 6800/03 (5-04) 

FEDERAL DEPOSIT INSURANCE CORPORATION

 WASHINGTON, D.C. 20429 OMB APPROVAL

OMB NUMBER: 3064-0030 

EXPIRES: 04/30/2026

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response...1.0 

FORM 3 

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

FDIC FORM 6800/03

(12 C.F.R. 335.611)

THE FDIC IS AUTHORIZED TO SOLICIT THE INFORMATION REQUIRED BY THIS FORM PURSUANT TO SECTIONS 12(i), 16(a), 

and 23(a) OF THE SECURITIES EXCHANGE ACT OF 1934, AND THE RULES AND REGULATIONS THEREUNDER.

SEC RULES REFERENCED IN THIS FORM APPEAR AT 17 C.F.R. §§240.16a-1 THROUGH 16e-1.

DISCLOSURE OF INFORMATION SPECIFIED ON THIS FORM IS MANDATORY. THE INFORMATION WILL BE USED FOR THE 

PRIMARY PURPOSE OF DISCLOSING THE HOLDINGS OF DIRECTORS, OFFICERS, AND BENEFICIAL OWNERS OF 

REGISTERED COMPANIES. INFORMATION DISCLOSED WILL BE A MATTER OF PUBLIC RECORD AND AVAILABLE FOR 

INSPECTION BY MEMBERS OF THE PUBLIC. THE FDIC CAN USE IT IN INVESTIGATIONS OR LITIGATION INVOLVING THE 

FEDERAL SECURITIES LAWS OR OTHER CIVIL, CRIMINAL, OR REGULATORY STATUTES OR PROVISIONS, AS WELL AS FOR 

REFERRAL TO OTHER GOVERNMENTAL AUTHORITIES AND SELF-REGULATORY ORGANIZATIONS. FAILURE TO DISCLOSE 

REQUIRED INFORMATION MAY RESULT IN CIVIL OR CRIMINAL ACTION AGAINST PERSONS INVOLVED FOR VIOLATIONS OF 

THE FEDERAL SECURITIES LAWS AND RULES.

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 CURRENT, VALID OMB CONTROL NUMBER.
FDIC 6800/03 (5-04) Page 2

GENERAL INSTRUCTIONS

1. Who Must File

(a) This form must be filed by the following persons (“reporting person”):

(i) any director or officer of a bank with a class of equity securities registered pursuant to Section 12 of the 

Securities Exchange Act of 1934 (“Exchange Act”); (Note: Title is not determinative for purposes of determining “officer” 

status. See SEC Rule 16a-1(f) for the definition of “officer”);

(ii) any beneficial owner of greater than 10% of a class of equity securities registered under Section 12 of the 

Exchange Act, as determined by voting or investment control over the securities pursuant to SEC Rule 16a-1(a)(1) (“10 

percent holder”); and

(iii) any trust, trustee, beneficiary, or settlor required to report pursuant to SEC Rule 16a-8.

(b) If a reporting person is not an officer, director, or 10 percent holder, the person should check “other” in Item 5 

(Relationship of Reporting Person to Bank) and describe the reason for reporting status in the space provided.

(c) If a person described above does not beneficially own any securities required to be reported (See SEC Rule 

16a-1 and Instruction 5), the person is required to file this form and state that no securities are beneficially owned.

2. When Form Must Be Filed

(a) This form must be filed within 10 days after the event by which the person becomes a reporting person (i.e., 

officer, director, 10 percent holder or other person). This form and any amendment is deemed filed with the appropriate 

Federal Banking Agency upon electronic receipt on business days during the hours of 8:00 a.m. until 10:00 p.m. Eastern 

Standard Time or Eastern Daylight Saving Time, whichever is currently in effect. A form received after these business 

hours will be deemed filed at 8:00 a.m. on the following business day. If this form is submitted through FDICconnect on a 

non-business day, it will be deemed filed at 8:00 a.m. on the following business day. Business days include all weekdays 

that are not Federal holidays. A paper form submitted by a reporting person that has obtained a hardship exemption 

under applicable FDIC rules will be deemed filed with the FDIC on the date it is received by the FDIC. If this form is 

required to be filed on an exchange, this form and any amendment is deemed filed with the exchange on the date it is 

received by the exchange.

(b) A reporting person of a bank that is registering securities for the first time under Section 12 of the Exchange Act 

must file this form no later than the effective date of the registration statement.

(c) A separate form shall be filed to reflect beneficial ownership of securities of each bank.

3. Where Form Must Be Filed

(a) A reporting person must file Form 3 in electronic format using the secure, Internet based, FDICconnect 

Business Center to access the interagency Beneficial Ownership Filings system, except that a filing person that has 

obtained a hardship exemption under applicable FDIC rules (see Section 335.801(b) may file the form in paper format. 

For information and answers to questions regarding beneficial ownership and the completion and filing of the forms, 

please contact the FDIC Division of Supervision and Consumer Protection, Accounting and Securities Disclosure Section, 

550 17th Street, N.W., Washington, D.C. 20429. For technical questions or problems relating to the use of FDICconnect 

or Designated Coordinator registration, contact FDICconnect toll-free at 877-275-3342 or via 

E-mail at FDICconnect@fdic.gov.

(b) At the time this form or any amendment is filed with the FDIC, file one copy with each Exchange on which any 

class of securities of the bank is registered. If the bank has designated a single Exchange to receive Section 16 filings, 

the copy shall be filed with that Exchange only.

(c) Any person required to file this form or amendment shall, no later than at the time the form or amendment is 

transmitted for filing with the FDIC, send or deliver a copy to the person designated by the bank to receive the copy or, if 

no person is so designated, the bank’s corporate secretary (or person performing similar functions) in accordance with 

SEC Rule 16a-3(e).
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Note: If filing pursuant to a hardship exemption under FDIC rules, file three copies of this form or any amendment, at least 

one of which is signed, with the FDIC in accordance with applicable rules. (Acknowledgement of receipt by the agency 

may be obtained by enclosing a self-addressed stamped postcard or envelop identifying the form or amendment filed.)

4. Class of Securities Reported

(a) Persons reporting pursuant to Section 16(a) of the Exchange Act shall include information as to their beneficial 

ownership of any class of equity securities of the bank, even though one or more of such classes may not be registered 

pursuant to Section 12 of the Exchange Act.

(b) The title of the security should clearly identify the class, even if the bank has only one class of securities 

outstanding; for example: “Common Stock,” “Class A Common Stock,” “Class B Convertible Preferred Stock,” etc.

(c) The amount of securities beneficially owned should state the face amount of debt securities (U.S. Dollars) or the 

number of equity securities, whichever is appropriate.

5. Holdings Required to Be Reported

(a) General Requirements

Report holdings of each class of securities of the bank beneficially owned as of the date of the event requiring the filing of 

this form. See Instruction 4 as to securities required to be reported.

(b) Beneficial Ownership Reported (Pecuniary Interest)

(i) Although, for purposes of determining status as 10 percent holder, a person is deemed to beneficially own 

securities over which that person has voting or investment control (See SEC Rule 16a-1(a)(1)), for reporting purposes, a 

person is deemed to be the beneficial owner of securities if that person has or shares the opportunity, directly or indirectly, 

to profit or share in any profit derived from a transaction in the securities (“pecuniary interest”). See SEC Rule 16a1(a)(2). See also SEC Rule 16a-8 for the application of the beneficial ownership definition to trust holdings and 

transactions.

(ii) Both direct and indirect beneficial ownership of securities shall be reported. Securities beneficially owned 

directly are those held in the reporting person’s name or in the name of a bank, broker or nominee for the account of the 

reporting person. In addition, securities held as joint tenants, tenants in common, tenants by the entirety, or as community

property are to be reported as held directly. If a person has a pecuniary interest, by reason of any contract, understanding 

or relationship (including a family relationship or arrangement) in securities held in the name of another person, that 

person is an indirect beneficial owner of those securities. See SEC Rule 16a-1(a)(2)(ii) for certain indirect beneficial 

ownerships.

(iii) Report securities beneficially owned directly on a separate line from those beneficially owned indirectly. 

Report different forms of indirect ownership on separate lines. The nature of indirect ownership shall be stated as 

specifically as possible; for example, “By Self as Trustee for X,” “By Spouse,” “By X Trust,” “By Y Corporation,” etc.

(iv) In stating the amount of securities owned indirectly through a partnership, corporation, trust, or other entity, 

report the number of securities representing the reporting person’s proportionate interest in securities beneficially owned 

by that entity. Alternatively, at the option of the reporting person, the entire amount of the entity’s interest may be 

reported. See SEC Rule 16a-1(a)(2)(ii)(B) and SEC Rule 16a-1(a)(2)(iii).

(v) Where more than one person beneficially owns the same equity securities, such owners may file Form 3 

individually or jointly. Joint and group filings may be made by any designated beneficial owner. Holdings of securities 

owned separately by any joint or group filer are permitted to be included in the joint filing. Indicate the name and address 

of the designated reporting person in Item 1 of Form 3 and attach a list of the names and addresses of each other 

reporting person. Joint and group filings must include all required information for each beneficial owner, and such filings 

must be signed by each beneficial owner, or on behalf of such owner by an authorized person. Use the Filer Information 

screen in the interagency Beneficial Ownership Filings system to submit additional joint or group filers' names and related 

filing information required by this form.

If this form is being filed in paper format pursuant to a hardship exemption and the space provided for signatures is 

insufficient, attach a signature page. If this form is being filed in paper format, submit any attached listing of names or 

signatures on another Form 3, a copy of Form 3, or a separate sheet of 8 1⁄2 by 11 inch white paper, indicate the number 
FDIC 6800/03 (5-04) Page 4

of pages comprising the report (form plus attachments) at the bottom of each report page (e.g., 1 of 3, 2 of 3, 3 of 3), and 

include the name of the designated filer and information required by Items 2 and 3 of the form on the attachment.

See SEC Rule 16a-3(i) regarding signatures.

(c) Non-Derivative and Derivative Securities

(i) Report non-derivative securities beneficially owned in Table I and derivative securities (e.g., puts, calls, 

options, warrants, convertible securities, or other rights or obligations to buy or sell securities) beneficially owned in Table 

II. Derivative securities beneficially owned that are both equity securities and convertible or exchangeable for other equity 

securities (e.g., convertible preferred securities) should be reported only on Table II.

(ii) The title of a derivative security and the title of the equity security underlying the derivative security should 

be shown separately in the appropriate columns in Table II. The “puts” and “calls” reported in Table II include, in addition

to separate puts and calls, any combination of the two, such as spreads and straddles. In reporting an option in Table II, 

state whether it represents a right to buy, a right to sell, an obligation to buy, or an obligation to sell the equity securities 

subject to the option.

(iii) Describe in the appropriate columns in Table II characteristics of derivative securities, including title, 

exercise or conversion price, date exercisable, expiration date, and the title and amount of securities underlying the 

derivative security.

(iv) Securities constituting components of a unit shall be reported separately on the applicable table (e.g., if a 

unit has a non-derivative security component and a derivative security component, the non-derivative security component 

shall be reported in Table I and the derivative security component shall be reported in Table II). The relationship between

individual securities comprising the unit shall be indicated in the space provided for explanation of responses.

6. Additional Information

(a) If space provided in the line items on this Form 3 is insufficient, identify and enter additional information and 

footnotes under Explanation of Responses.

(b) If the space provided in the line items on the paper Form 3 or space provided for additional comments is 

insufficient, attach another Form 3, copy of Form 3 or separate 8 1⁄2 by 11 inch white paper to Form 3, completed as 

appropriate to include the additional comments. Each attached page must include information required in Items 1, 2 and 3 

of the form. The number of pages comprising the report (form plus attachments) shall be indicated at the bottom of each

report page (e.g., 1 of 3, 2 of 3, 3 of 3).

(c) If one or more exhibits are included with the form, provide a reference to such exhibit(s) under Explanation of 

Responses. If the exhibit is being filed in paper format pursuant to a hardship exemption under applicable FDIC rules, 

place the designation “P” (paper) next to the name of the exhibit in the exhibit reference. 

(d) If additional information is not reported in this manner, it will be assumed that no additional information was 

provided.

7. Signature

(a) If the form is filed for an individual, it shall be signed by that person or specifically on behalf of the individual by 

a person authorized to sign for the individual. If signed on behalf of the individual by another person, the authority of such 

person to sign the form shall be confirmed to the FDIC in writing in an attachment to the form or as soon as practicable in 

an amendment by the individual for whom the form is filed, unless such a confirmation still in effect is on file with the 

FDIC. The confirming statement need only indicate that the reporting person authorizes and designates the named 

person or persons to file the form on the reporting person’s behalf, and state the duration of the authorization.

(b) If the form is filed for a corporation, partnership, trust, or other entity, the capacity in which the individual signed 

shall be set forth (e.g., John Smith, Secretary, on behalf of X Corporation). 

8. Amendments
FDIC 6800/03 (5-04) Page 5

(a) If this form is filed as an amendment in order to add one or more lines of ownership information to Table I or 

Table II of the form being amended, provide each line being added, together with one or more footnotes, under 

Explanation of Responses as necessary to explain the addition of the line or lines. Do not repeat lines of ownership 

information that were disclosed in the original form and are not being amended.

(b) If this form is filed as an amendment in order to amend one or more lines of ownership information that already 

were disclosed in Table I or Table II of the form being amended, provide the complete line or lines being amended, as 

amended, together with notes under Explanation of Responses as necessary to explain the amendment of the line or 

lines. Do not repeat lines of ownership information that were disclosed in the original form and are not being amended.

(c) If this form is filed as an amendment for any other purpose other than or in addition to the purpose described in 

items (a) or (b) of this General Instruction 8, provide one or more notes under Explanation of Responses, as necessary, to 

explain the amendment.