# EDGAR Filing Document

**Accession Number:** 0001464521
**File Stem:** 0001062993-25-014850
**Filing Date:** 2025-8
**Character Count:** 20135
**Document Hash:** 674d6191c8ef0f767f7ef10a64e97ed7
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001062993-25-014850.hdr.sgml**: 20250822

**ACCESSION NUMBER**: 0001062993-25-014850

**CONFORMED SUBMISSION TYPE**: 3

**PUBLIC DOCUMENT COUNT**: 1

**CONFORMED PERIOD OF REPORT**: 20250807

**FILED AS OF DATE**: 20250822

**DATE AS OF CHANGE**: 20250822

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** HealthCor Partners Fund LP
- **CENTRAL INDEX KEY:** 0001408660

**ORGANIZATION NAME:**
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-42790
- **FILM NUMBER:** 251247151

**BUSINESS ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
- **BUSINESS PHONE:** (212) 622-7726

**MAIL ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** HealthCor Partners GP, LLC
- **CENTRAL INDEX KEY:** 0001519460

**ORGANIZATION NAME:**
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-42790
- **FILM NUMBER:** 251247149

**BUSINESS ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
- **BUSINESS PHONE:** 212-622-7726

**MAIL ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** HealthCor Partners LP
- **CENTRAL INDEX KEY:** 0001519456

**ORGANIZATION NAME:**
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-42790
- **FILM NUMBER:** 251247150

**BUSINESS ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
- **BUSINESS PHONE:** 212-622-7871

**MAIL ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** HCPCIV 1, LLC
- **CENTRAL INDEX KEY:** 0002083103

**ORGANIZATION NAME:**
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-42790
- **FILM NUMBER:** 251247146

**BUSINESS ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
- **BUSINESS PHONE:** 212-622-7726

**MAIL ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** HealthCor Partners Management LP
- **CENTRAL INDEX KEY:** 0001519462

**ORGANIZATION NAME:**
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-42790
- **FILM NUMBER:** 251247152

**BUSINESS ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
- **BUSINESS PHONE:** (212) 622-7726

**MAIL ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** HealthCor Partners Fund II, L.P.
- **CENTRAL INDEX KEY:** 0001538581

**ORGANIZATION NAME:**
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-42790
- **FILM NUMBER:** 251247148

**BUSINESS ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
- **BUSINESS PHONE:** 212-622-7726

**MAIL ADDRESS:**
- **STREET 1:** 186 SEVEN FARMS DRIVE, SUITE F-371
- **CITY:** DANIEL ISLAND
- **STATE:** SC
- **ZIP:** 29492
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** HealthCor Partners II, L.P.
- **CENTRAL INDEX KEY:** 0001643094

**ORGANIZATION NAME:**
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**FILING VALUES:**
- **FORM TYPE:** 3
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-42790
- **FILM NUMBER:** 251247147

**BUSINESS ADDRESS:**
- **STREET 1:** 152 W. 57TH STREET, 43RD FLOOR
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10019
- **BUSINESS PHONE:** 212-622-7731

**MAIL ADDRESS:**
- **STREET 1:** 152 W. 57TH STREET, 43RD FLOOR
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10019
**ISSUER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** Heartflow, Inc.
- **CENTRAL INDEX KEY:** 0001464521
- **STANDARD INDUSTRIAL CLASSIFICATION:** SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841]
- **ORGANIZATION NAME:** 08 Industrial Applications and Services
- **EIN:** 260506743
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 0811

**BUSINESS ADDRESS:**
- **STREET 1:** 331 E EVELYN AVENUE
- **CITY:** MOUNTAIN VIEW
- **STATE:** CA
- **ZIP:** 94041
- **BUSINESS PHONE:** 650-241-1221

**MAIL ADDRESS:**
- **STREET 1:** 331 E EVELYN AVENUE
- **CITY:** MOUNTAIN VIEW
- **STATE:** CA
- **ZIP:** 94041

**FORMER COMPANY:**
- **FORMER CONFORMED NAME:** Cardiovascular Simulation, Inc.
- **DATE OF NAME CHANGE:** 20090519

### 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>HealthCor Partners Management LP<br><sub>(Last) (First) (Middle)</sub><br>186 SEVEN FARMS DRIVE, SUITE F-371<br><sub>(Street)</sub><br>DANIEL ISLAND, SC 29492<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Heartflow, Inc. [ HTFL ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2025-08-07 | **4. 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>_ _ | **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>HealthCor Partners Fund LP<br><sub>(Last) (First) (Middle)</sub><br>186 SEVEN FARMS DRIVE, SUITE F-371<br><sub>(Street)</sub><br>DANIEL ISLAND, SC 29492<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Heartflow, Inc. [ HTFL ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2025-08-07 | **4. 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>_ _ | **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>HealthCor Partners LP<br><sub>(Last) (First) (Middle)</sub><br>186 SEVEN FARMS DRIVE, SUITE F-371<br><sub>(Street)</sub><br>DANIEL ISLAND, SC 29492<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Heartflow, Inc. [ HTFL ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2025-08-07 | **4. 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>_ _ | **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>HealthCor Partners GP, LLC<br><sub>(Last) (First) (Middle)</sub><br>186 SEVEN FARMS DRIVE, SUITE F-371<br><sub>(Street)</sub><br>DANIEL ISLAND, SC 29492<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Heartflow, Inc. [ HTFL ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2025-08-07 | **4. 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>_ _ | **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>HealthCor Partners Fund II, L.P.<br><sub>(Last) (First) (Middle)</sub><br>186 SEVEN FARMS DRIVE, SUITE F-371<br><sub>(Street)</sub><br>DANIEL ISLAND, SC 29492<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Heartflow, Inc. [ HTFL ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2025-08-07 | **4. 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>_ _ | **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>HealthCor Partners II, L.P.<br><sub>(Last) (First) (Middle)</sub><br>186 SEVEN FARMS DRIVE, SUITE F-371<br><sub>(Street)</sub><br>DANIEL ISLAND, SC 29492<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Heartflow, Inc. [ HTFL ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2025-08-07 | **4. 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>_ _ | **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>HCPCIV 1, LLC<br><sub>(Last) (First) (Middle)</sub><br>186 SEVEN FARMS DRIVE, SUITE F-371<br><sub>(Street)</sub><br>DANIEL ISLAND, SC 29492<br><sub>(City) (State) (Zip)</sub> | **3. Issuer Name and Ticker or Trading Symbol**<br>Heartflow, Inc. [ HTFL ] | **5. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  |
| **2. Date of Event Requiring Statement (Month/Day/Year)**<br>2025-08-07 | **4. 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>_ _ | **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 |
| Series C Preferred | <sup>(1)</sup> | <sup>(1)</sup> | Common Stock | 1248939<sup>(1)</sup> | <sup>(1)</sup> | I | By HealthCor Partners Fund, L.P.<sup>(2)(9)</sup> |
| Series C Preferred | <sup>(1)</sup> | <sup>(1)</sup> | Common Stock | 624471<sup>(1)</sup> | <sup>(1)</sup> | I | By HealthCor Partners Fund II, L.P.<sup>(3)(9)</sup> |
| Series D Preferred | <sup>(4)</sup> | <sup>(4)</sup> | Common Stock | 1630231<sup>(4)</sup> | <sup>(4)</sup> | I | By HCPCIV I, LLC<sup>(5)(9)</sup> |
| Series D Preferred | <sup>(4)</sup> | <sup>(4)</sup> | Common Stock | 208604<sup>(4)</sup> | <sup>(4)</sup> | I | By HealthCor Partners Fund II, L.P.<sup>(3)(9)</sup> |
| Series E Preferred Stock | <sup>(6)</sup> | <sup>(6)</sup> | Common Stock | 1099378<sup>(6)</sup> | <sup>(6)</sup> | I | By HCPCIV I, LLC<sup>(5)(9)</sup> |
| Series F Preferred Stock | <sup>(7)</sup> | <sup>(7)</sup> | Common Stock | 1337337<sup>(7)</sup> | <sup>(7)</sup> | I | By HCPCIV I, LLC<sup>(5)(9)</sup> |
| Series F-1 Preferred Stock | <sup>(7)</sup> | <sup>(7)</sup> | Common Stock | 452528<sup>(7)</sup> | <sup>(7)</sup> | I | By HCPCIV I, LLC<sup>(5)(9)</sup> |
| Convertible Promissory Note | <sup>(8)</sup> | <sup>(8)</sup> | Common Stock |  | <sup>(8)</sup> | I | By HCPCIV I, LLC<sup>(5)(9)</sup> |

---

### Footnotes:

(1) Each share of Series C preferred stock is convertible on a 1 to 0.5764 basis into shares of Heartflow, Inc.'s ("Heartflow") common stock and has no expiration date.  The Series C preferred stock will automatically convert into the underlying shares of common stock upon the closing of Heartflow's initial public offering.  The conversion rate gives effect to the 1 for 2.92 reverse stock split of Heartflow's common stock, which became effective on July 31, 2025.

(2) HealthCor Partners Fund, L.P. ("HCP Fund") is a private investment partnership which is the direct beneficial owner of the securities reported herein. The shares held by HCP Fund may be deemed to be beneficially owned by HealthCor Partners L.P. ("HCPLP"), its general partner, and by HealthCor Partners GP, LLC ("HCPGP"), the general partner of HCPLP. Each of HCPLP and HCPGP hereby disclaims any beneficial ownership of shares held by HCP Fund except to the extent of any pecuniary interest therein.

(3) HealthCor Partners Fund II, L.P. ("HCPII Fund") is a private investment partnership which is the direct beneficial owner of the securities reported herein. The shares held by HCPII Fund may be deemed to be beneficially owned by HealthCor Partners II, L.P. ("HCP2LP"), its general partner, and by HCPGP, the general partner of HCP2LP. Each of HCP2LP and HCPGP hereby disclaims any beneficial ownership of shares held by HCPII Fund except to the extent of any pecuniary interest therein.

(4) Each share of Series D preferred stock is convertible on a 1 to 0.6467 basis into shares of Heartflow's common stock and has no expiration date.  The Series D preferred stock will automatically convert into the underlying shares of common stock upon the closing of Heartflow's initial public offering. The conversion rate gives effect to the 1 for 2.92 reverse stock split of Heartflow's common stock, which became effective on July 31, 2025.

(5) HCPCIV 1, LLC ("HCPCIV") is a private investment limited liability company which is the direct beneficial owner of the securities reported herein. The shares held by HCPCIV may be determined to be beneficially owned by HCP2LP, its managing member, and by HCPGP. Each of HCP2LP and HCPGP hereby disclaims any beneficial ownership of shares held by HCPCIV except to the extent of any pecuniary interest therein.

(6) Each share of Series E preferred stock is convertible on a 1 to 0.6951 basis into shares of Heartflow's common stock and has no expiration date.  The Series E preferred stock will automatically convert into the underlying shares of common stock upon the closing of Heartflow's initial public offering. The conversion rate gives effect to the 1 for 2.92 reverse stock split of Heartflow's common stock, which became effective on July 31, 2025.

(7) Each share of Series F preferred stock and Series F-1 preferred stock is convertible on a 1 to 0.3425 basis into shares of Heartflow's common stock and has no expiration date.  The Series F preferred stock and Series F-1 preferred stock will automatically convert into the underlying shares of common stock upon the closing of Heartflow's initial public offering. The conversion rate gives effect to the 1 for 2.92 reverse stock split of Heartflow's common stock, which became effective on July 31, 2025.

(8) Represents the outstanding principal amount of a convertible promissory note held by HCPCIV 1, LLC, which will automatically convert upon the consummation of Heartflow's initial public offering into shares of common stock at a conversion price of 80% of the price per share in Heartflow's initial public offering, subject to a valuation ceiling of $2.0 billion.  These shares of common stock issuable upon conversion of the convertible promissory note have no expiration date.

(9) HealthCor Partners Management, L.P. is the investment manager for each of HCP Fund, HCPH Fund, and HCPCIV and has voting and investment discretion with respect to such entities' securities reported herein.  HealthCor Partners Management, L.P. hereby disclaims any beneficial ownership of shares held by HCP Fund, HCPH Fund, and HCPCIV except to the extent of any pecuniary interest therein.

**Signature:** HealthCor Partners Management, L.P., by HealthCor Partners GP, LLC, general partner, by /s/ Jeffrey C. Lightcap, Senior Managing Director  
**Date:** 2025-08-22

**Signature:** HealthCor Partners Fund, L.P., by HealthCor Partners, L.P., general partner, by HealthCor Partners GP, LLC, its General Partner, by /s/ Jeffrey C. Lightcap, Senior Managing Director  
**Date:** 2025-08-22

**Signature:** HealthCor Partners, L.P.,  by HealthCor Partners GP, LLC, general partner, by /s/ Jeffrey C. Lightcap, Senior Managing Director  
**Date:** 2025-08-22

**Signature:** HealthCor Partners GP, LLC, by /s/ Jeffrey C. Lightcap, Senior Managing Director  
**Date:** 2025-08-22

**Signature:** HealthCor Partners Fund II, L.P., by HealthCor Partners II, L.P., general partner, by HealthCor Partners GP, LLC, its general partner, by /s/ Jeffrey C. Lightcap, Senior Managing Director  
**Date:** 2025-08-22

**Signature:** HealthCor Partners II, L.P., by HealthCor Partners GP, LLC, its general partner, by /s/ Jeffrey C. Lightcap, Senior Managing Director  
**Date:** 2025-08-22

**Signature:** HCPCIV 1, LLC, by HealthCor Partners II, L.P., its managing member, by HealthCor Partners GP, LLC, its general partner, by /s/ Jeffrey C. Lightcap, Senior Managing Director  
**Date:** 2025-08-22

### 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.**