# EDGAR Filing Document

**Accession Number:** 0001587526
**File Stem:** 0001209191-23-000184
**Filing Date:** 2023-1
**Character Count:** 20621
**Document Hash:** ea79d611191ebd7ba00f705e253b9912
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001209191-23-000184.hdr.sgml**: 20230103

**ACCESSION NUMBER**: 0001209191-23-000184

**CONFORMED SUBMISSION TYPE**: 4

**PUBLIC DOCUMENT COUNT**: 3

**CONFORMED PERIOD OF REPORT**: 20221229

**FILED AS OF DATE**: 20230103

**DATE AS OF CHANGE**: 20230103

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** ELCA, LLC
- **CENTRAL INDEX KEY:** 0001587543

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-36089
- **FILM NUMBER:** 23502265

**BUSINESS ADDRESS:**
- **STREET 1:** C/O RINGCENTRAL, INC.
- **STREET 2:** 1400 FASHION ISLAND BLVD, 7TH FLOOR
- **CITY:** SAN MATEO
- **STATE:** CA
- **ZIP:** 94404
- **BUSINESS PHONE:** 650-472-4100

**MAIL ADDRESS:**
- **STREET 1:** C/O RINGCENTRAL, INC.
- **STREET 2:** 1400 FASHION ISLAND BLVD, 7TH FLOOR
- **CITY:** SAN MATEO
- **STATE:** CA
- **ZIP:** 94404
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Shmunis Vladimir
- **CENTRAL INDEX KEY:** 0001586647

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-36089
- **FILM NUMBER:** 23502270

**MAIL ADDRESS:**
- **STREET 1:** C/O RINGCENTRAL, INC.
- **STREET 2:** 20 DAVIS DRIVE
- **CITY:** BELMONT
- **STATE:** CA
- **ZIP:** 94002
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Shmunis Sandra
- **CENTRAL INDEX KEY:** 0001587526

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-36089
- **FILM NUMBER:** 23502269

**MAIL ADDRESS:**
- **STREET 1:** C/O RINGCENTRAL, INC.
- **STREET 2:** 1400 FASHION ISLAND BLVD, 7TH FLOOR
- **CITY:** SAN MATEO
- **STATE:** CA
- **ZIP:** 94404
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** ELCA Fund III, LP
- **CENTRAL INDEX KEY:** 0001587622
- **STATE OF INCORPORATION:** CA
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-36089
- **FILM NUMBER:** 23502266

**BUSINESS ADDRESS:**
- **STREET 1:** C/O RINGCENTRAL, INC.
- **STREET 2:** 1400 FASHION ISLAND BLVD, 7TH FLOOR
- **CITY:** SAN MATEO
- **STATE:** CA
- **ZIP:** 94404
- **BUSINESS PHONE:** 650-472-4100

**MAIL ADDRESS:**
- **STREET 1:** C/O RINGCENTRAL, INC.
- **STREET 2:** 1400 FASHION ISLAND BLVD, 7TH FLOOR
- **CITY:** SAN MATEO
- **STATE:** CA
- **ZIP:** 94404
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** ELCA Fund I, LP
- **CENTRAL INDEX KEY:** 0001587616
- **STATE OF INCORPORATION:** CA
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-36089
- **FILM NUMBER:** 23502268

**BUSINESS ADDRESS:**
- **STREET 1:** C/O RINGCENTRAL, INC.
- **STREET 2:** 1400 FASHION ISLAND BLVD, 7TH FLOOR
- **CITY:** SAN MATEO
- **STATE:** CA
- **ZIP:** 94404
- **BUSINESS PHONE:** 650-472-4100

**MAIL ADDRESS:**
- **STREET 1:** C/O RINGCENTRAL, INC.
- **STREET 2:** 1400 FASHION ISLAND BLVD, 7TH FLOOR
- **CITY:** SAN MATEO
- **STATE:** CA
- **ZIP:** 94404
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** ELCA Fund II, LP
- **CENTRAL INDEX KEY:** 0001587618
- **STATE OF INCORPORATION:** CA
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-36089
- **FILM NUMBER:** 23502267

**BUSINESS ADDRESS:**
- **STREET 1:** C/O RINGCENTRAL, INC.
- **STREET 2:** 1400 FASHION ISLAND BLVD, 7TH FLOOR
- **CITY:** SAN MATEO
- **STATE:** CA
- **ZIP:** 94404
- **BUSINESS PHONE:** 650-472-4100

**MAIL ADDRESS:**
- **STREET 1:** C/O RINGCENTRAL, INC.
- **STREET 2:** 1400 FASHION ISLAND BLVD, 7TH FLOOR
- **CITY:** SAN MATEO
- **STATE:** CA
- **ZIP:** 94404
**ISSUER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** RingCentral, Inc.
- **CENTRAL INDEX KEY:** 0001384905
- **STANDARD INDUSTRIAL CLASSIFICATION:** SERVICES-COMPUTER PROCESSING & DATA PREPARATION [7374]
- **IRS NUMBER:** 943322844
- **FISCAL YEAR END:** 1231

**BUSINESS ADDRESS:**
- **STREET 1:** 20 DAVIS DRIVE
- **CITY:** BELMONT
- **STATE:** CA
- **ZIP:** 94002
- **BUSINESS PHONE:** 650-472-4100

**MAIL ADDRESS:**
- **STREET 1:** 20 DAVIS DRIVE
- **CITY:** BELMONT
- **STATE:** CA
- **ZIP:** 94002

**FORMER COMPANY:**
- **FORMER CONFORMED NAME:** RingCentral Inc
- **DATE OF NAME CHANGE:** 20070103

## Exhibit 24.1

```
<PRE>
                                POWER OF ATTORNEY

The undersigned, as a Section 16 reporting person of RingCentral, Inc.
(the "Company"), hereby constitutes and appoints John Marlow, Paul Porter,
and Jessica Van Patten, and each of them, the undersigned's true and
lawful attorney-in-fact, to:

      1. complete and execute Forms 3, 4 and 5 and other forms and all
amendments thereto as such attorney-in-fact shall in his or her discretion
determine to be required or advisable pursuant to Section 16 of the
Securities Exchange Act of 1934 (as amended) and the rules and regulations
promulgated thereunder, or any successor laws and regulations, as a
consequence of the undersigned's ownership, acquisition or disposition of
securities of the Company; and

      2. do all acts necessary in order to file such forms with the U.S.
Securities and Exchange Commission, any securities exchange or national
association, the Company and such other person or agency as the attorney-
in-fact shall deem appropriate.

      The undersigned hereby ratifies and confirms all that said attorneys-
in-fact and agents shall do or cause to be done by virtue hereof.  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 Securities Exchange Act of 1934 (as amended).

      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 the Company and the foregoing attorneys-in-fact.

      IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney
to be executed as of this 27 day of April, 2022.

      					Signature: /s/ Sandra Shmunis
      					Print Name: Sandra Shmunis

</PRE>
```

## Exhibit 24.2

```
<PRE>
                                POWER OF ATTORNEY

The undersigned, as a Section 16 reporting person of RingCentral, Inc.
(the "Company"), hereby constitutes and appoints John Marlow, Paul Porter,
and Jessica Van Patten, and each of them, the undersigned's true and
lawful attorney-in-fact, to:

      1. complete and execute Forms 3, 4 and 5 and other forms and all
amendments thereto as such attorney-in-fact shall in his or her discretion
determine to be required or advisable pursuant to Section 16 of the
Securities Exchange Act of 1934 (as amended) and the rules and regulations
promulgated thereunder, or any successor laws and regulations, as a
consequence of the undersigned's ownership, acquisition or disposition of
securities of the Company; and

      2. do all acts necessary in order to file such forms with the U.S.
Securities and Exchange Commission, any securities exchange or national
association, the Company and such other person or agency as the attorney-
in-fact shall deem appropriate.

      The undersigned hereby ratifies and confirms all that said attorneys-
in-fact and agents shall do or cause to be done by virtue hereof.  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 Securities Exchange Act of 1934 (as amended).

      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 the Company and the foregoing attorneys-in-fact.

      IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney
to be executed as of this 27 day of April, 2022.

      					ELCA Fund I, LP
					ELCA Fund II, LP
					ELCA Fund III, LP
					ELCA, LLC

					Signature: /s/ Sandra Shmunis
      					Print Name: Sandra Shmunis

					Title: Managing Member of ELCA, LLC,
					the General Partner of ELCA Fund I, LP,
					ELCA Fund II, LP and ELCA Fund III, LP

</PRE>
```

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

## FORM 4

### 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>Shmunis Vladimir<br><sub>(Last) (First) (Middle)</sub><br>C/O RINGCENTRAL, INC.<br>20 DAVIS DRIVE<br><sub>(Street)</sub><br>BELMONT, CA 94002<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-12-29 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [ ] 10% Owner<br>[X] Officer (give title below) [ ] Other (specify below)<br>_CEO & Chairman_ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>RingCentral, Inc. [ RNG ] | **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>Shmunis Sandra<br><sub>(Last) (First) (Middle)</sub><br>C/O RINGCENTRAL, INC.<br>20 DAVIS DRIVE<br><sub>(Street)</sub><br>BELMONT, CA 94002<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-12-29 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [ ] 10% Owner<br>[ ] Officer (give title below) [X] Other (specify below)<br>_Wife of Reporting Person_ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>RingCentral, Inc. [ RNG ] | **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>ELCA Fund I, LP<br><sub>(Last) (First) (Middle)</sub><br>C/O RINGCENTRAL, INC.<br>20 DAVIS DRIVE<br><sub>(Street)</sub><br>BELMONT, CA 94002<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-12-29 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [ ] 10% Owner<br>[ ] Officer (give title below) [X] Other (specify below)<br>_Controlled by Reporting Person_ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>RingCentral, Inc. [ RNG ] | **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>ELCA Fund II, LP<br><sub>(Last) (First) (Middle)</sub><br>C/O RINGCENTRAL, INC.<br>20 DAVIS DRIVE<br><sub>(Street)</sub><br>BELMONT, CA 94002<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-12-29 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [ ] 10% Owner<br>[ ] Officer (give title below) [X] Other (specify below)<br>_Controlled by Reporting Person_ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>RingCentral, Inc. [ RNG ] | **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>ELCA Fund III, LP<br><sub>(Last) (First) (Middle)</sub><br>C/O RINGCENTRAL, INC.<br>20 DAVIS DRIVE<br><sub>(Street)</sub><br>BELMONT, CA 94002<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-12-29 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [ ] 10% Owner<br>[ ] Officer (give title below) [X] Other (specify below)<br>_Controlled by Reporting Person_ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>RingCentral, Inc. [ RNG ] | **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>ELCA, LLC<br><sub>(Last) (First) (Middle)</sub><br>C/O RINGCENTRAL, INC.<br>20 DAVIS DRIVE<br><sub>(Street)</sub><br>BELMONT, CA 94002<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2022-12-29 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [ ] 10% Owner<br>[ ] Officer (give title below) [X] Other (specify below)<br>_Controlled by Reporting Person_ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>RingCentral, Inc. [ RNG ] | **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 |
| Class A Common Stock | 2022-12-29 |  | C<sup>(1)</sup> |  | 35000 | A | $0.00 | 35000 | I | By ELCA Fund I, L.P.<sup>(2)</sup> |
| Class A Common Stoc | 2022-12-29 |  | G | V | 35000 | D | $0.00 | 0 | I | By ELCA Fund I, L.P.<sup>(2)</sup> |
| Class A Common Stock |  |  |  |  |  |  |  | 241175 | D |  |

---

## 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 |
| Class B Common Stock | <sup>(3)</sup> | 2022-12-29 |  | C<sup>(1)</sup> |  |  | 35000 | <sup>(3)</sup> | <sup>(3)</sup> | Class A Common Stock | 35000 | $0.00 | 5457107 | I | By ELCA Fund I, L.P.<sup>(2)</sup> |
| Class B Common Stock | <sup>(3)</sup> |  |  |  |  |  |  | <sup>(3)</sup> | <sup>(3)</sup> | Class A Common Stock | 5926 |  | 5926 | I | By ELCA Fund II, L.P.<sup>(2)</sup> |
| Class B Common Stock | <sup>(3)</sup> |  |  |  |  |  |  | <sup>(3)</sup> | <sup>(3)</sup> | Class A Common Stock | 5926 |  | 5926 | I | By ELCA Fund III, L.P.<sup>(2)</sup> |
| Class B Common Stock | <sup>(3)</sup> |  |  |  |  |  |  | <sup>(3)</sup> | <sup>(3)</sup> | Class A Common Stock | 1385 |  | 1385 | I | By ELCA, LLC<sup>(2)</sup> |
| Class B Common Stock | <sup>(3)</sup> |  |  |  |  |  |  | <sup>(3)</sup> | <sup>(3)</sup> | Class A Common Stock | 1274 |  | 1274 | I | By Trust<sup>(4)</sup> |

---

### Footnotes:

(1) Each share of Class A Common Stock was issued upon conversion of one share of Class B Common Stock.

(2) Vladimir Shmunis and Sandra Shmunis are the managing members of ELCA, LLC. ELCA, LLC is the general partner of ELCA Fund I, L.P., ELCA Fund II, L.P., and ELCA Fund III, L.P. By virtue of this relationship, Mr. Shmunis and Mrs. Shmunis may be deemed to share voting and dispositive power with respect to the shares held by ELCA Fund I, L.P., and certain of the shares held by ELCA Fund II, L.P. and ELCA Fund III, L.P. Each of the Reporting Persons disclaims beneficial ownership of these securities except to the extent of its pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes.

(3) Each share of Class B Common Stock is convertible at any time at the option of the holder into one share of Class A Common Stock and has no expiration date. In addition, each share of Class B Common Stock held by a shareholder will convert automatically into one share of Class A Common Stock upon (i) any transfer of such share (subject to certain exceptions), or (ii) the occurrence of certain other specific instances, including the vote of the holders of the Class B Common Stock, as set forth in the issuer's Amended and Restated Certificate of Incorporation.

(4) Shares are held by the Shmunis Revocable Trust dated June 9, 1998, as amended, for which Vladimir Shmunis and Sandra Shmunis are trustees and beneficiaries.

**Signature:** /s/ Paul Porter, attorney-in-fact for Vladimir Shmunis  
**Date:** 2023-01-03

**Signature:** /s/ Paul Porter, attorney-in-fact for Sandra Shmunis  
**Date:** 2023-01-03

**Signature:** /s/ Paul Porter, attorney-in-fact for Sandra Shmunis, a Managing Member of ELCA, LLC, the General Partner of ELCA Fund I, L.P.  
**Date:** 2023-01-03

**Signature:** /s/ Paul Porter, attorney-in-fact for Sandra Shmunis, a Managing Member of ELCA, LLC, the General Partner of ELCA Fund II, L.P.  
**Date:** 2023-01-03

**Signature:** /s/ Paul Porter, attorney-in-fact for Sandra Shmunis, a Managing Member of ELCA, LLC, the General Partner of ELCA Fund III, L.P.  
**Date:** 2023-01-03

**Signature:** /s/ Paul Porter, attorney-in-fact for Sandra Shmunis, a Managing Member of ELCA, LLC  
**Date:** 2023-01-03

### 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.**