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Get and Sign Fdic Annual Beneficial Edit Form
Statement for Issuer’s Fiscal
Year Ended (Month/Day/Year)
OMB NUMBER: 3064-0030
EXPIRES: 07/31/2013
Estimated average burden
hours per response ...1.0
(PLEASE PRINT OR TYPE ALL RESPONSES)
Form 4 transactions reported.
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5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
Director
10% Owner
Officer (Give title below)
Other (Specify below)
4. If Amendment, Date Original
Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check applicable...
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