# EDGAR Filing Document

**Accession Number:** 0001878897
**File Stem:** 0001193125-25-253443
**Filing Date:** 2025-10
**Character Count:** 20048
**Document Hash:** 98e10e0df51edc9ef7530327675ebf28
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001193125-25-253443.hdr.sgml**: 20251028

**ACCESSION NUMBER**: 0001193125-25-253443

**CONFORMED SUBMISSION TYPE**: 4

**PUBLIC DOCUMENT COUNT**: 2

**CONFORMED PERIOD OF REPORT**: 20251024

**FILED AS OF DATE**: 20251028

**DATE AS OF CHANGE**: 20251028

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Richman Darren
- **CENTRAL INDEX KEY:** 0001594474

**ORGANIZATION NAME:**

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41054
- **FILM NUMBER:** 251424689

**MAIL ADDRESS:**
- **STREET 1:** 80 BROAD STREET, 22ND FLOOR
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10004
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** CHENE DAVID
- **CENTRAL INDEX KEY:** 0001797237

**ORGANIZATION NAME:**

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41054
- **FILM NUMBER:** 251424690

**MAIL ADDRESS:**
- **STREET 1:** 80 BROAD STREET, 22ND FLOOR
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10004
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Kennedy Lewis Investment Holdings II LLC
- **CENTRAL INDEX KEY:** 0001854977

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

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41054
- **FILM NUMBER:** 251424693

**BUSINESS ADDRESS:**
- **STREET 1:** 111 WEST 33RD STREET
- **STREET 2:** SUITE 1910
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10120
- **BUSINESS PHONE:** 212-782-3480

**MAIL ADDRESS:**
- **STREET 1:** 111 WEST 33RD STREET
- **STREET 2:** SUITE 1910
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10120
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** KLCP Fund III (EU) Master AIV LP
- **CENTRAL INDEX KEY:** 0002029655

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

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41054
- **FILM NUMBER:** 251424691

**BUSINESS ADDRESS:**
- **STREET 1:** C/O KENNEDY LEWIS MANAGEMENT LP
- **STREET 2:** 225 LIBERTY STREET, SUITE 4210
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10281
- **BUSINESS PHONE:** 212.782.3480

**MAIL ADDRESS:**
- **STREET 1:** C/O KENNEDY LEWIS MANAGEMENT LP
- **STREET 2:** 225 LIBERTY STREET, SUITE 4210
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10281
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Kennedy Lewis GP III LLC
- **CENTRAL INDEX KEY:** 0001897209

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

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41054
- **FILM NUMBER:** 251424694

**BUSINESS ADDRESS:**
- **STREET 1:** 111 WEST 33RD STREET
- **STREET 2:** SUITE 1910
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10120
- **BUSINESS PHONE:** 212.782.3480

**MAIL ADDRESS:**
- **STREET 1:** 111 WEST 33RD STREET
- **STREET 2:** SUITE 1910
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10120
**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** KLIM Delta HQC3 LP
- **CENTRAL INDEX KEY:** 0001994226

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

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 001-41054
- **FILM NUMBER:** 251424692

**BUSINESS ADDRESS:**
- **STREET 1:** 225 LIBERTY STREET
- **STREET 2:** SUITE 4210
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10281
- **BUSINESS PHONE:** (212) 782-3840

**MAIL ADDRESS:**
- **STREET 1:** 225 LIBERTY STREET
- **STREET 2:** SUITE 4210
- **CITY:** NEW YORK
- **STATE:** NY
- **ZIP:** 10281
**ISSUER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** Douglas Elliman Inc.
- **CENTRAL INDEX KEY:** 0001878897
- **STANDARD INDUSTRIAL CLASSIFICATION:** REAL ESTATE AGENTS & MANAGERS (FOR OTHERS) [6531]
- **ORGANIZATION NAME:** 05 Real Estate & Construction
- **EIN:** 872176850
- **STATE OF INCORPORATION:** DE
- **FISCAL YEAR END:** 1231

**BUSINESS ADDRESS:**
- **STREET 1:** 4400 BISCAYNE BLVD
- **STREET 2:** FLOOR 10
- **CITY:** MIAMI
- **STATE:** FL
- **ZIP:** 33137
- **BUSINESS PHONE:** 3055798000

**MAIL ADDRESS:**
- **STREET 1:** 4400 BISCAYNE BLVD
- **STREET 2:** FLOOR 10
- **CITY:** MIAMI
- **STATE:** FL
- **ZIP:** 33137

## Exhibit 99.1

**Exhibit 99.1**

**Form 4 Joint Filer Information**

---

| | |
|:---|:---|
| &nbsp;&nbsp; <br>Name:<br>| &nbsp;&nbsp; <br>Kennedy Lewis Investment Holdings II LLC |
| &nbsp;&nbsp; <br>Address:<br>| &nbsp;&nbsp; <br>225 Liberty Street, Suite 4210<br>New York, NY 10281 |
| &nbsp;&nbsp; <br>Date of Event Requiring Statement:<br>| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br>10/24/2025 |

---

---

| | |
|:---|:---|
| &nbsp;&nbsp; <br>Name:<br>| &nbsp;&nbsp; <br>KLIM Delta HQC3 LP |
| &nbsp;&nbsp; <br>Address:<br>| &nbsp;&nbsp; <br>225 Liberty Street, Suite 4210<br>New York, NY 10281 |
| &nbsp;&nbsp; <br>Date of Event Requiring Statement:<br>| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br>10/24/2025 |

---

---

| | |
|:---|:---|
| &nbsp;&nbsp; <br>Name:<br>| &nbsp;&nbsp; <br>KLCP Fund III (EU) Master AIV LP |
| &nbsp;&nbsp; <br>Address:<br>| &nbsp;&nbsp; <br>225 Liberty Street, Suite 4210<br>New York, NY 10281 |
| &nbsp;&nbsp; <br>Date of Event Requiring Statement:<br>| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br>10/24/2025 |

---

<u> Name: </u> <u> David Chene</u> <br> <u> Address:</u> <u> 225 Liberty Street, Suite 4210</u>

------

  <u>New York, NY 10281 </u> <br> <u> Date of Event Requiring Statement: </u> <u> 10/24/2025</u>

---

| | |
|:---|:---|
| &nbsp;&nbsp; <br>Name:<br>| &nbsp;&nbsp; <br>Darren Richman |
| &nbsp;&nbsp; <br>Address:<br>| &nbsp;&nbsp; <br>225 Liberty Street, Suite 4210<br>New York, NY 10281 |
| &nbsp;&nbsp; <br>Date of Event Requiring Statement:<br>| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br>10/24/2025 |

---

------

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

## FORM 4

### STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

[x] 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>Kennedy Lewis GP III LLC<br><sub>(Last) (First) (Middle)</sub><br>225 LIBERTY STREET, SUITE 4210<br><sub>(Street)</sub><br>NEW YORK, NY 10281<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2025-10-24 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [ ] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Douglas Elliman Inc. [ DOUG ] | **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>Kennedy Lewis Investment Holdings II LLC<br><sub>(Last) (First) (Middle)</sub><br>225 LIBERTY STREET, SUITE 4210<br><sub>(Street)</sub><br>NEW YORK, NY 10281<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2025-10-24 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [ ] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Douglas Elliman Inc. [ DOUG ] | **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>KLIM Delta HQC3 LP<br><sub>(Last) (First) (Middle)</sub><br>225 LIBERTY STREET, SUITE 4210<br><sub>(Street)</sub><br>NEW YORK, NY 10281<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2025-10-24 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [ ] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Douglas Elliman Inc. [ DOUG ] | **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>KLCP Fund III (EU) Master AIV LP<br><sub>(Last) (First) (Middle)</sub><br>225 LIBERTY STREET, SUITE 4210<br><sub>(Street)</sub><br>NEW YORK, NY 10281<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2025-10-24 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [ ] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Douglas Elliman Inc. [ DOUG ] | **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>CHENE DAVID<br><sub>(Last) (First) (Middle)</sub><br>225 LIBERTY STREET, SUITE 4210<br><sub>(Street)</sub><br>NEW YORK, NY 10281<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2025-10-24 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [ ] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Douglas Elliman Inc. [ DOUG ] | **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>Richman Darren<br><sub>(Last) (First) (Middle)</sub><br>225 LIBERTY STREET, SUITE 4210<br><sub>(Street)</sub><br>NEW YORK, NY 10281<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2025-10-24 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[X] Director [ ] 10% Owner<br>[ ] Officer (give title below) [ ] Other (specify below)<br>_ _ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>Douglas Elliman Inc. [ DOUG ] | **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 |
|  |  |  |  |  |  |  |  |  |  |  |

---

## 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 |
| Senior Secured Convertible Promissory Note | <sup>(8)(9)</sup> | 2025-10-24 |  | D<sup>(1)</sup> |  |  | 1<sup>(6)(8)(9)</sup> | <sup>(6)</sup> | <sup>(6)</sup> | Common Stock | 30526740<sup>(6)(8)(9)</sup> | <sup>(1)</sup> | 0 | I | See Footnotes<sup>(2)(4)(5)</sup> |
| Senior Secured Convertible Promissory Note | <sup>(8)(9)</sup> | 2025-10-24 |  | D<sup>(1)</sup> |  |  | 1<sup>(7)(8)(9)</sup> | <sup>(7)</sup> | <sup>(7)</sup> | Common Stock | 2806594<sup>(7)(8)(9)</sup> | <sup>(1)</sup> | 0 | I | See Footnotes<sup>(3)(4)(5)</sup> |

---

### Footnotes:

(1) On October 24, 2025, in connection with the sale by an indirect subsidiary of Douglas Elliman Inc. (the "Issuer") of the equity interests it held in another indirect subsidiary of the Issuer to a third party, the Issuer repurchased the previously reported Senior Secured Convertible Promissory Notes (collectively, the "Convertible Notes") held by KLCP Fund III (EU) Master AIV LP ("KLCP Fund III") and KLIM Delta HQC3 LP ("KLIM Delta", and together with KLCP Fund III, the "Funds") for an aggregate purchase price of $95,000,000.  In connection with the repurchase of the Convertible Notes, on October 24, 2025, David Chene, a Manager of Kennedy Lewis Investment Holdings II LLC ("Holdings II"), resigned from the Issuer's Board of Directors.

(2) These securities were held by KLCP Fund III.

(3) These securities were held by KLIM Delta.

(4) Kennedy Lewis GP III LLC ("Kennedy Lewis GP III") is the general partner of each of the Funds. Holdings II is the managing member of Kennedy Lewis GP III. Holdings II is controlled by its board of managers. David Chene and Darren Richman, each a Manager of Holdings II, are the effective control persons of Holdings II. Each of Kennedy Lewis GP III, Holdings II, David Chene and Darren Richman may have been deemed to exercise voting and investment power over and thus may have been deemed to have beneficially owned the securities reported herein that were held by the Funds due to their relationship with the Funds.

(5) For purposes of Section 16 of the Securities Exchange Act of 1934, each of Kennedy Lewis GP III, Holdings II, David Chene and Darren Richman disclaims beneficial ownership of the securities of the Issuer reported herein that were held directly by the Funds except to the extent of its or his pecuniary interest therein, and this report shall not be deemed an admission that any of Kennedy Lewis GP III, Holdings II, David Chene or Darren Richman was the beneficial owner of such securities for purposes of Section 16 or any other purpose.

(6) This Convertible Note between KLCP Fund III and the Issuer was due July 2, 2029, had a principal amount of $45,790,109.01 and bore interest at a rate of 7.0% per annum payable in cash, or, if no Event of Default (as defined in such Convertible Note) had occurred or was continuing, at the Issuer's election, 8.0% per annum paid in kind, due semi-annually. The maturity date of this Convertible Note was July 2, 2029.

(7) This Convertible Note between KLIM Delta and the Issuer was due July 2, 2029, had a principal amount of $4,209,890.99 and bore interest at a rate of 7.0% per annum payable in cash, or, if no Event of Default (as defined in such Convertible Note) had occurred or was continuing, at the Issuer's election, 8.0% per annum paid in kind, due semi-annually. The maturity date of this Convertible Note was July 2, 2029.

(8) The Funds had the right to elect at any time to convert their respective Convertible Notes into shares of common stock, par value $0.01 per share ("Common Stock"), of the Issuer at an initial conversion price equal to $1.50 per share of Common Stock, subject to adjustment as set forth in the Convertible Notes, so long as the aggregate number of shares of Common Stock beneficially owned by such Fund, together with its affiliates and any member of a Section 13(d) group with such Fund or any of its affiliates, would not exceed 4.99% of the number of shares of Common Stock outstanding immediately after giving effect to the conversion (the "Beneficial Ownership Limitation").

(9) (Continued from footnote 8) The Funds had the right to increase or decrease the Beneficial Ownership Limitation upon no less than 61 days' prior written notice to the Issuer, provided that the Beneficial Ownership Limitation could in no event exceed 24.99% of the number of shares of Common Stock outstanding immediately after giving effect to the conversion. The conversion price was subject to certain customary anti-dilution adjustments.

**Remarks:**
As David Chene, a Manager of Kennedy Lewis Investment Holdings II LLC, has resigned from the Board of Directors of Douglas Elliman Inc. (the "Issuer"), each of the reporting persons other than Mr. Chene are no longer deemed to be directors by deputization of the Issuer.

**Signature:** KENNEDY LEWIS GP III LLC, By: Kennedy Lewis Investment Holdings II LLC, its managing member, Name: /s/ Anthony Pasqua, Title: Authorized Person  
**Date:** 2025-10-28

**Signature:** KENNEDY LEWIS INVESTMENT HOLDINGS II LLC, Name: /s/ Anthony Pasqua, Title: Authorized Person  
**Date:** 2025-10-28

**Signature:** KLIM DELTA HQC3 LP, By: Kennedy Lewis GP III LLC, its general partner,  By: Kennedy Lewis Investment Holdings II LLC, its managing member, Name: /s/ Anthony Pasqua, Title: Authorized Person  
**Date:** 2025-10-28

**Signature:** KLCP FUND III (EU) MASTER AIV LP, By: Kennedy Lewis GP III LLC, its general partner, By: Kennedy Lewis Investment Holdings II LLC, its managing member, Name: /s/ Anthony Pasqua, Title: Authorized Person  
**Date:** 2025-10-28

**Signature:** DAVID CHENE, Name: /s/ David Chene  
**Date:** 2025-10-28

**Signature:** DARREN RICHMAN, Name: /s/ Darren Richman  
**Date:** 2025-10-28

### 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.**