# EDGAR Filing Document

**Accession Number:** 0001805212
**File Stem:** 0000899243-23-004312
**Filing Date:** 2023-2
**Character Count:** 19912
**Document Hash:** 7f71c5620e971d8d68af6f20b5e2e81e
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0000899243-23-004312.hdr.sgml**: 20230208

**ACCESSION NUMBER**: 0000899243-23-004312

**CONFORMED SUBMISSION TYPE**: 3/A

**PUBLIC DOCUMENT COUNT**: 1

**CONFORMED PERIOD OF REPORT**: 20220826

**FILED AS OF DATE**: 20230208

**DATE AS OF CHANGE**: 20230208

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** BROWN BROTHERS HARRIMAN & CO
- **CENTRAL INDEX KEY:** 0000014661
- **STATE OF INCORPORATION:** NY

**FILING VALUES:**
- **FORM TYPE:** 3/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41485
- **FILM NUMBER:** 23600204

**BUSINESS ADDRESS:**
- **STREET 1:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005-1101
- **BUSINESS PHONE:** 2124938200

**MAIL ADDRESS:**
- **STREET 1:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005-1101
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** BBH Capital Partners V, L.P.
- **CENTRAL INDEX KEY:** 0001642711
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41485
- **FILM NUMBER:** 23600203

**BUSINESS ADDRESS:**
- **STREET 1:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005
- **BUSINESS PHONE:** 212-493-7749

**MAIL ADDRESS:**
- **STREET 1:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** BBH Capital Partners V-A, L.P.
- **CENTRAL INDEX KEY:** 0001642712
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41485
- **FILM NUMBER:** 23600202

**BUSINESS ADDRESS:**
- **STREET 1:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005
- **BUSINESS PHONE:** 212-493-7749

**MAIL ADDRESS:**
- **STREET 1:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** BBH CPV WCC Co-Investment LLC
- **CENTRAL INDEX KEY:** 0001805212
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41485
- **FILM NUMBER:** 23600201

**BUSINESS ADDRESS:**
- **STREET 1:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005
- **BUSINESS PHONE:** 212-493-8236

**MAIL ADDRESS:**
- **STREET 1:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Paquin Jean-Pierre
- **CENTRAL INDEX KEY:** 0001952865

**FILING VALUES:**
- **FORM TYPE:** 3/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41485
- **FILM NUMBER:** 23600198

**MAIL ADDRESS:**
- **STREET 1:** C/O BROWN BROTHERS HARRIMAN & CO.
- **STREET 2:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Kruczek Robert Patrick
- **CENTRAL INDEX KEY:** 0001934635

**FILING VALUES:**
- **FORM TYPE:** 3/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41485
- **FILM NUMBER:** 23600199

**MAIL ADDRESS:**
- **STREET 1:** 100 RIVER BLUFF DRIVE, SUITE 210
- **CITY:** LITTLE ROCK
- **STATE:** AR
- **ZIP:** 72202
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Meskin Jeffrey B.
- **CENTRAL INDEX KEY:** 0001952856

**FILING VALUES:**
- **FORM TYPE:** 3/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41485
- **FILM NUMBER:** 23600200

**MAIL ADDRESS:**
- **STREET 1:** C/O BROWN BROTHERS HARRISON & CO.
- **STREET 2:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Langer Bradley M.
- **CENTRAL INDEX KEY:** 0001952858

**FILING VALUES:**
- **FORM TYPE:** 3/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41485
- **FILM NUMBER:** 23600197

**MAIL ADDRESS:**
- **STREET 1:** C/O BROWN BROTHERS HARRIMAN & CO.
- **STREET 2:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Boylan Michael A.
- **CENTRAL INDEX KEY:** 0001953300

**FILING VALUES:**
- **FORM TYPE:** 3/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41485
- **FILM NUMBER:** 23600196

**MAIL ADDRESS:**
- **STREET 1:** C/O BROWN BROTHERS HARRIMAN & CO.
- **STREET 2:** 140 BROADWAY
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10005
**ISSUER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** Westrock Coffee Co
- **CENTRAL INDEX KEY:** 0001806347
- **STANDARD INDUSTRIAL CLASSIFICATION:** BEVERAGES [2080]
- **IRS NUMBER:** 264767812
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**BUSINESS ADDRESS:**
- **STREET 1:** 100 RIVER BLUFF DRIVE
- **STREET 2:** SUITE 210
- **CITY:** LITTLE ROCK
- **STATE:** AR
- **ZIP:** 72202
- **BUSINESS PHONE:** (501) 320-4880

**MAIL ADDRESS:**
- **STREET 1:** 100 RIVER BLUFF DRIVE
- **STREET 2:** SUITE 210
- **CITY:** LITTLE ROCK
- **STATE:** AR
- **ZIP:** 72202

**FORMER COMPANY:**
- **FORMER CONFORMED NAME:** Westrock Coffee Holdings, LLC
- **DATE OF NAME CHANGE:** 20200311

### UNITED STATES SECURITIES AND EXCHANGE COMMISSION
**Washington, D.C. 20549**

## FORM 3/A

### STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).

[ ] Check this box to indicate that a transaction was made pursuant to a contract, instruction or written plan for the purchase or sale of equity securities of the issuer that is intended to satisfy the affirmative defense conditions of Rule 10b5-1(c). See Instruction 10.

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>BROWN BROTHERS HARRIMAN & CO<br><sub>(Last) (First) (Middle)</sub><br>140 BROADWAY<br><sub>(Street)</sub><br>NEW YORK, NY 10005<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-08-26 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Westrock Coffee Co [ WEST ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>BBH Capital Partners V, L.P.<br><sub>(Last) (First) (Middle)</sub><br>140 BROADWAY<br><sub>(Street)</sub><br>NEW YORK, NY 10005<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-08-26 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Westrock Coffee Co [ WEST ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>BBH Capital Partners V-A, L.P.<br><sub>(Last) (First) (Middle)</sub><br>140 BROADWAY<br><sub>(Street)</sub><br>NEW YORK, NY 10005<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-08-26 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Westrock Coffee Co [ WEST ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>BBH CPV WCC Co-Investment LLC<br><sub>(Last) (First) (Middle)</sub><br>140 BROADWAY<br><sub>(Street)</sub><br>NEW YORK, NY 10005<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-08-26 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Westrock Coffee Co [ WEST ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>Meskin Jeffrey B.<br><sub>(Last) (First) (Middle)</sub><br>140 BROADWAY<br><sub>(Street)</sub><br>NEW YORK, NY 10005<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-08-26 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Westrock Coffee Co [ WEST ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>Kruczek Robert Patrick<br><sub>(Last) (First) (Middle)</sub><br>140 BROADWAY<br><sub>(Street)</sub><br>NEW YORK, NY 10005<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-08-26 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Westrock Coffee Co [ WEST ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>Paquin Jean-Pierre<br><sub>(Last) (First) (Middle)</sub><br>140 BROADWAY<br><sub>(Street)</sub><br>NEW YORK, NY 10005<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-08-26 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Westrock Coffee Co [ WEST ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>Langer Bradley M.<br><sub>(Last) (First) (Middle)</sub><br>140 BROADWAY<br><sub>(Street)</sub><br>NEW YORK, NY 10005<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-08-26 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Westrock Coffee Co [ WEST ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>Boylan Michael A.<br><sub>(Last) (First) (Middle)</sub><br>140 BROADWAY<br><sub>(Street)</sub><br>NEW YORK, NY 10005<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-08-26 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [X] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Westrock Coffee Co [ WEST ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[ ] Form filed by One Reporting Person<br>[X] Form filed by More than One Reporting Person |

---

## Table I - Non-Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | 3. Transaction Code (V) | 3. Transaction Code (V) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | Code | V | Amount | (A) or (D) | Price | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| Series A Convertible Preferred Stock |  |  |  |  |  |  |  | 10919673 | I | See Footnotes<sup>(1)(4)(5)(6)(7)</sup> |
| Series A Convertible Preferred Stock |  |  |  |  |  |  |  | 220654 | I | See Footnotes<sup>(2)(4)(5)(6)(7)</sup> |
| Series A Convertible Preferred Stock |  |  |  |  |  |  |  | 8171430 | I | See Footnotes<sup>(3)(4)(5)(6)(7)</sup> |

---

## Table II - Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | 4. Transaction Code (V) | 4. Transaction Code (V) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 6. Date Exercisable and Expiration Date | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Underlying Securities | 7. Title and Amount of Underlying Securities | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |

---

### Footnotes:

(1) Reflects securities directly held by BBH Capital Partners V, L.P. ("BBH CPV").

(2) Reflects securities directly held by BBH Capital Partners V-A, L.P. ("BBH CPV-A").

(3) Reflects securities directly held by BBH CPV WCC Co-Investment LLC. ("BBH CPV Co-Invest")

(4) BBH Capital Partners ("BBHCP") manages private equity investments through its funds, including BBH CPV, BBH CPV-A and BBH CPV Co-Invest (the "Record Holders").  Each of the Record Holders are controlled and managed by a general partner, BBH Private Capital Management V, LLC (the "General Partner").  Brown Brothers Harriman & Co. ("BBH"), a New York limited partnership, serves as the managing member of the General Partner.

(5) BBH has designated each of Jeffrey Meskin, Patrick Kruczek, JP Paquin, Bradley Langer and Michael Boylan, as the sole and exclusive persons at BBH having voting power (including the power to vote or to direct the vote) and investment power (including the power to dispose or to direct the disposition) with respect to all securities held by the Record Holders. Each Reporting Person disclaims beneficial ownership of the reported securities except to the extent of their pecuniary interest therein.

(6) Information with respect to each of the Reporting Persons is given solely by such Reporting Person, and no Reporting Person has responsibility for the accuracy or completeness of information supplied by another Reporting Person.

(7) Each of the Reporting Persons (other than to the extent it directly holds securities reported herein) disclaims beneficial ownership of the securities held by the other Reporting Persons, except to the extent of such Reporting Person's pecuniary interest therein, and, pursuant to Rule 16a-1(a)(4) under the Securities Exchange Act of 1934 (the "Exchange Act"), each of the Reporting Persons (other than to the extent it directly holds securities reported herein) states that the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of all of the securities reported herein for purposes of Section 16 of the Exchange Act or for any other purpose.

**Signature:** BROWN BROTHERS HARRIMAN & CO., By: /s/ Jeffrey B. Meskin, Partner  
**Date:** 2023-02-08

**Signature:** BBH CAPITAL PARTNERS V, L.P., By: BBH Private Capital Management, its general partner, By: /s/ Jeffrey B. Meskin, Title: Partner of BBH & Co., Managing Member of BBH Private Capital Management V, LLC  
**Date:** 2023-02-08

**Signature:** BBH CAPITAL PARTNERS V-A, L.P., By: BBH Private Capital Management, its general partner, By: /s/ Jeffrey B. Meskin, Title: Partner of BBH & Co., Managing Member of BBH Private Capital Management V, LLC  
**Date:** 2023-02-08

**Signature:** BBH CPV WCC CO-INVESTMENT LLC, By: BBH Private Capital Management, its manager, By: /s/ Jeffrey B. Meskin, , Title: Partner of BBH & Co., Managing Member of BBH Private Capital Management V, LLC  
**Date:** 2023-02-08

**Signature:** /s/ Jeffrey B. Meskin, Partner, Brown Brothers Harriman & Co.; Managing Member, BBH Private Capital Management V, LLC  
**Date:** 2023-02-08

**Signature:** /s/ Patrick Kruczek, Managing Director, Brown Brothers Harriman & Co.; Member, BBH Private Capital Management V, LLC  
**Date:** 2023-02-08

**Signature:** /s/ JP Paquin, Partner, Brown Brothers Harriman & Co.; Member, BBH Private Capital Management V, LLC  
**Date:** 2023-02-08

**Signature:** /s/ Bradley Langer, Managing Director, Brown Brothers Harriman & Co.; Member, BBH Private Capital Management V, LLC  
**Date:** 2023-02-08

**Signature:** /s/ Michael Boylan, Managing Director, Brown Brothers Harriman & Co.; Member, BBH Private Capital Management V, LLC  
**Date:** 2023-02-08

### Remarks:

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).

** 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.

**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 Number.**