1. Title of Derivate Security  (Instr. 4) | 2. Date Exercisable and Expiration Date  (MM/DD/YYYY) | 3. Title and Amount of Securities Underlying Derivative Security  (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)  (Instr. 5) | 6. Nature of Indirect Beneficial Ownership  (Instr. 5) |