# EDGAR Filing Document

**Accession Number:** 0001959879
**File Stem:** 0001209191-23-006116
**Filing Date:** 2023-2
**Character Count:** 19975
**Document Hash:** 32ba954b844a1b298c2cf6a1d8e21a3c
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001209191-23-006116.hdr.sgml**: 20230202

**ACCESSION NUMBER**: 0001209191-23-006116

**CONFORMED SUBMISSION TYPE**: 3

**PUBLIC DOCUMENT COUNT**: 2

**CONFORMED PERIOD OF REPORT**: 20230131

**FILED AS OF DATE**: 20230202

**DATE AS OF CHANGE**: 20230202

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Seldin David
- **CENTRAL INDEX KEY:** 0001959900

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39489
- **FILM NUMBER:** 23579951

**MAIL ADDRESS:**
- **STREET 1:** 12610 RACE TRACK ROAD
- **STREET 2:** SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Haring-Smith Whitney
- **CENTRAL INDEX KEY:** 0001846535

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39489
- **FILM NUMBER:** 23579944

**MAIL ADDRESS:**
- **STREET 1:** 12610 RACE TRACT ROAD, SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Anzu Nuburu V LLC
- **CENTRAL INDEX KEY:** 0001959879
- **STATE OF INCORPORATION:** FL
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39489
- **FILM NUMBER:** 23579947

**BUSINESS ADDRESS:**
- **STREET 1:** 12610 RACE TRACK ROAD
- **STREET 2:** SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
- **BUSINESS PHONE:** 813-814-9898

**MAIL ADDRESS:**
- **STREET 1:** 12610 RACE TRACK ROAD
- **STREET 2:** SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Anzu Nuburu LLC
- **CENTRAL INDEX KEY:** 0001959884
- **STATE OF INCORPORATION:** FL
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39489
- **FILM NUMBER:** 23579949

**BUSINESS ADDRESS:**
- **STREET 1:** 12610 RACE TRACK ROAD
- **STREET 2:** SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
- **BUSINESS PHONE:** 813-814-9898

**MAIL ADDRESS:**
- **STREET 1:** 12610 RACE TRACK ROAD
- **STREET 2:** SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** David & Jennifer Michael Family Ltd Partnership
- **CENTRAL INDEX KEY:** 0001960188
- **STATE OF INCORPORATION:** CA
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39489
- **FILM NUMBER:** 23579945

**BUSINESS ADDRESS:**
- **STREET 1:** 6835 PASEO LAREDO
- **CITY:** LA JOLLA
- **STATE:** CA
- **ZIP:** 92037
- **BUSINESS PHONE:** 813-814-9898

**MAIL ADDRESS:**
- **STREET 1:** 6835 PASEO LAREDO
- **CITY:** LA JOLLA
- **STATE:** CA
- **ZIP:** 92037
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Herman Debrah
- **CENTRAL INDEX KEY:** 0001959913

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39489
- **FILM NUMBER:** 23579943

**MAIL ADDRESS:**
- **STREET 1:** 12610 RACE TRACK ROAD
- **STREET 2:** SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Anzu Partners LLC
- **CENTRAL INDEX KEY:** 0001959972
- **STATE OF INCORPORATION:** FL
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39489
- **FILM NUMBER:** 23579950

**BUSINESS ADDRESS:**
- **STREET 1:** 12610 RACE TRACK ROAD
- **STREET 2:** SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
- **BUSINESS PHONE:** 813-814-9898

**MAIL ADDRESS:**
- **STREET 1:** 12610 RACE TRACK ROAD
- **STREET 2:** SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Anzu Nuburu III LLC
- **CENTRAL INDEX KEY:** 0001960024
- **STATE OF INCORPORATION:** FL
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39489
- **FILM NUMBER:** 23579948

**BUSINESS ADDRESS:**
- **STREET 1:** 12610 RACE TRACK ROAD
- **STREET 2:** SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
- **BUSINESS PHONE:** 813-814-9898

**MAIL ADDRESS:**
- **STREET 1:** 12610 RACE TRACK ROAD
- **STREET 2:** SUITE 250
- **CITY:** TAMPA
- **STATE:** FL
- **ZIP:** 33626
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** CST Global LLC
- **CENTRAL INDEX KEY:** 0001960132
- **STATE OF INCORPORATION:** WY
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-39489
- **FILM NUMBER:** 23579946

**BUSINESS ADDRESS:**
- **STREET 1:** 6835 PASEO LAREDO
- **CITY:** LA JOLLA
- **STATE:** CA
- **ZIP:** 92037
- **BUSINESS PHONE:** 813-814-9898

**MAIL ADDRESS:**
- **STREET 1:** 6835 PASEO LAREDO
- **CITY:** LA JOLLA
- **STATE:** CA
- **ZIP:** 92037
**ISSUER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** Nuburu, Inc.
- **CENTRAL INDEX KEY:** 0001814215
- **STANDARD INDUSTRIAL CLASSIFICATION:** MISCELLANEOUS ELECTRICAL MACHINERY, EQUIPMENT & SUPPLIES [3690]
- **IRS NUMBER:** 000000000
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**BUSINESS ADDRESS:**
- **STREET 1:** 7442 S TUSCON WAY
- **STREET 2:** SUITE 130
- **CITY:** CENTENNIAL
- **STATE:** CO
- **ZIP:** 80112
- **BUSINESS PHONE:** (720) 767-1400

**MAIL ADDRESS:**
- **STREET 1:** 7442 S TUSCON WAY
- **STREET 2:** SUITE 130
- **CITY:** CENTENNIAL
- **STATE:** CO
- **ZIP:** 80112

**FORMER COMPANY:**
- **FORMER CONFORMED NAME:** Tailwind Acquisition Corp.
- **DATE OF NAME CHANGE:** 20200604

## Ex-24

```
<PRE>
Exhibit 24 - POWER OF ATTORNEY

       	Know all by these presents, that the undersigned hereby constitutes and
appoints each of Daniel Hirsch and Debrah Herman, and with full power of
substitution, as the undersigned's true and lawful attorney-in-fact to:

	(1)	execute for and on behalf of the undersigned, in the undersigned's capacity
as a director and/or 10% owner of Nuburu, Inc., a Delaware corporation (the
"Company"), Forms 3, 4, and 5 in accordance with Section 16 of the Securities
Exchange Act of 1934, as amended, (the "Exchange Act") and the rules thereunder;

	(2)	do and perform any and all acts for and on behalf of the undersigned which
may be necessary or desirable to complete and execute any such Form 3, 4, or 5,
complete and execute any amendment or amendments thereto, and timely file such
form with the U.S. Securities and Exchange Commission and any stock exchange or
similar authority; and

	(3)	take any other action of any type whatsoever in connection with the
foregoing which, in the opinion of any such attorney-in-fact, may be of benefit
to, in the best interest of, or legally required by, the undersigned, it being
understood that the documents executed by any such attorney-in-fact on behalf of
the undersigned pursuant to this Power of Attorney shall be in such form and
shall contain such terms and conditions as such attorney-in-fact may approve in
any such attorney-in-fact's discretion.

       	The undersigned hereby grants to each such attorney-in-fact full power
and authority to do and perform any and every act and thing whatsoever
requisite, necessary, or proper to be done in the exercise of any of the rights
and powers herein granted, as fully to all intents and purposes as the
undersigned might or could do if personally present, with full power of
substitution or revocation, hereby ratifying and confirming all that each such
attorney-in-fact, or each such attorney-in-fact's substitute or substitutes,
shall lawfully do or cause to be done by virtue of this power of attorney and
the rights and powers herein granted.  The undersigned acknowledges that the
foregoing attorneys-in-fact, in serving in such capacity at the request of the
undersigned, are not assuming, nor is the Company assuming, any of the
undersigned's responsibilities to comply with Section 16 of the Exchange Act.

       	This Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file Forms 3, 4, and 5 with respect to the
undersigned's holdings of and transactions in securities issued by the Company,
unless earlier revoked by the undersigned in a signed writing delivered to each
of the foregoing attorneys-in-fact.

IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of this 27th  day of January, 2023.

Anzu Nuburu LLC

By: /s/ David Seldin
Name:   David Seldin
Title:  Manager

Anzu Nuburu II LLC

By: /s/ David Seldin
Name:   David Seldin
Title:  Manager

Anzu Nuburu III LLC

By: /s/ David Seldin
Name:   David Seldin
Title:  Manager

Anzu Nuburu V LLC

By: /s/ David Seldin
Name:   David Seldin
Title:  Manager

Anzu Partners LLC

By: /s/ David Seldin
Name:   David Seldin
Title:  Manager

David M. Seldin

/s/ David Seldin

David & Jennifer Michael Family Ltd Partnership

By: /s/ David Michael
Name:   David Michael
Title:  General Partner

CST Global LLC

By: /s/ David Michael
Name:   David Michael
Title:  Manager

Whitney Haring-Smith

/s/ Whitney Haring-Smith

Debrah Herman

/s/ Debrah Herman

</PRE>
```

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

## FORM 3

### INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>Seldin David<br><sub>(Last) (First) (Middle)</sub><br>12610 RACE TRACK ROAD, SUITE 250<br><sub>(Street)</sub><br>TAMPA, FL 33626<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Nuburu, Inc. [ BURU ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2023-01-31 | **4. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director   [X] 10% Owner<br>[ ] Officer (give title below)   [ ] Other (specify below)<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>Anzu Partners LLC<br><sub>(Last) (First) (Middle)</sub><br>12610 RACE TRACK ROAD, SUITE 250<br><sub>(Street)</sub><br>TAMPA, FL 33626<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Nuburu, Inc. [ BURU ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2023-01-31 | **4. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director   [X] 10% Owner<br>[ ] Officer (give title below)   [ ] Other (specify below)<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>Anzu Nuburu LLC<br><sub>(Last) (First) (Middle)</sub><br>12610 RACE TRACK ROAD, SUITE 250<br><sub>(Street)</sub><br>TAMPA, FL 33626<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Nuburu, Inc. [ BURU ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2023-01-31 | **4. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director   [X] 10% Owner<br>[ ] Officer (give title below)   [ ] Other (specify below)<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>Anzu Nuburu III LLC<br><sub>(Last) (First) (Middle)</sub><br>12610 RACE TRACK ROAD, SUITE 250<br><sub>(Street)</sub><br>TAMPA, FL 33626<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Nuburu, Inc. [ BURU ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2023-01-31 | **4. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director   [X] 10% Owner<br>[ ] Officer (give title below)   [ ] Other (specify below)<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>Anzu Nuburu V LLC<br><sub>(Last) (First) (Middle)</sub><br>12610 RACE TRACK ROAD, SUITE 250<br><sub>(Street)</sub><br>TAMPA, FL 33626<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Nuburu, Inc. [ BURU ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2023-01-31 | **4. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director   [X] 10% Owner<br>[ ] Officer (give title below)   [ ] Other (specify below)<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>CST Global LLC<br><sub>(Last) (First) (Middle)</sub><br>12610 RACE TRACK ROAD, SUITE 250<br><sub>(Street)</sub><br>TAMPA, FL 33626<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Nuburu, Inc. [ BURU ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2023-01-31 | **4. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director   [X] 10% Owner<br>[ ] Officer (give title below)   [ ] Other (specify below)<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>David & Jennifer Michael Family Ltd Partnership<br><sub>(Last) (First) (Middle)</sub><br>12610 RACE TRACK ROAD, SUITE 250<br><sub>(Street)</sub><br>TAMPA, FL 33626<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Nuburu, Inc. [ BURU ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2023-01-31 | **4. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director   [X] 10% Owner<br>[ ] Officer (give title below)   [ ] Other (specify below)<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>Haring-Smith Whitney<br><sub>(Last) (First) (Middle)</sub><br>12610 RACE TRACK ROAD, SUITE 250<br><sub>(Street)</sub><br>TAMPA, FL 33626<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Nuburu, Inc. [ BURU ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2023-01-31 | **4. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director   [X] 10% Owner<br>[ ] Officer (give title below)   [ ] Other (specify below)<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>Herman Debrah<br><sub>(Last) (First) (Middle)</sub><br>12610 RACE TRACK ROAD, SUITE 250<br><sub>(Street)</sub><br>TAMPA, FL 33626<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Nuburu, Inc. [ BURU ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2023-01-31 | **4. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director   [X] 10% Owner<br>[ ] Officer (give title below)   [ ] Other (specify below)<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 Beneficially Owned

---

|  |  |  |  |
| --- | --- | --- | --- |
| 1. Title of Security | 2. Amount of Securities Beneficially Owned | 3. Ownership Form | 4. Nature of Indirect Beneficial Ownership |

---

## Table II - Derivative Securities Beneficially Owned

---

|  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Derivative Security | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Underlying Securities | 3. Title and Amount of Underlying Securities | 4. Conversion or Exercise Price | 5. Ownership Form | 6. Nature of Indirect Beneficial Ownership |
| 1. Title of Derivative Security | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | 4. Conversion or Exercise Price | 5. Ownership Form | 6. Nature of Indirect Beneficial Ownership |
|  |  |  |  |  |  |  |  |

---

**Remarks:**
The Reporting Persons may be deemed members of a "group" for purposes of Section 13(d) of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), with each of the other Reporting Persons and Daniel Hirsch.

Mr. Seldin and Mr. Haring-Smith are managing partners of Anzu Partners LLC and share voting and dispositive power with respect to the securities held directly by Anzu Partners LLC.  Mr. Seldin, Mr. Hirsch and Ms. Herman are managers of each of Anzu Nuburu LLC, Anzu Nuburu II LLC, Anzu Nuburu III LLC and Anzu Nuburu V LLC (collectively, the "Anzu SPVs") and share voting and dispositive power with respect to the securities held directly by the Anzu SPVs. Mr. Hirsch is a director of Nuburu Inc.  Each of the Reporting Persons may be deemed a director by deputization of Nuburu Inc.

The Reporting Persons are jointly filing this Form 3 pursuant to Rule 16a-3(j) under the Exchange Act. This filing shall not be deemed an admission that the Reporting Persons are subject to Section 16 of the Exchange Act.

Exhibit List:  Exhibit 24 - Power of Attorney

**Signature:** /s/ Debrah Herman, attorney-in-fact for each of the Reporting Persons  
**Date:** 2023-02-02

### 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.**