LAKELAND BANCORP INC
5/A, 2000-02-02
STATE COMMERCIAL BANKS
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<PAGE>

                                                /------------------------------/
                                                /        OMB APPROVAL          /
                                                /------------------------------/
                                                / OMB Number:        3235-0362 /
                                                / Expires:  February 1, 1994   /
                                                / Estimated average burden     /
                                                / hours per response...... 1.0 /
                                                /------------------------------/

+--------+                                        U.S.
| FORM 5 |        1 of 3           SECURITIES AND EXCHANGE COMMISSION
+--------+                                Washington, D.C. 20549

[_] Check box if
    no longer subject     ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
    to Section 16.
    Form 4 or Form 5       Filed pursuant to Section 16(a) of the Securities
    obligations may           Exchange Act of 1934, Section 17(a) of the
    continue. See            Public Utility Holding Company Act of 1935 or
    Instruction 1(b).      Section 30(f) of the Investment Company Act of 1940

[_] Form 3 Holdings Reported

[_] Form 4 Transactions Reported
- --------------------------------------------------------------------------------
1.  Name and Address of Reporting Person

         BOHUNY,                     BRUCE                          G.
    ----------------------------------------------------------------------------
        (Last)                      (First)                        (Middle)

         C/O LAKELAND BANCORP, INC.
         250 OAK RIDGE ROAD
    ----------------------------------------------------------------------------
                                   (Street)

         OAK RIDGE,                  N.J.                              07438
    ----------------------------------------------------------------------------
        (City)                      (State)                           (Zip)


2.  Issuer Name and Ticker or Trading Symbol  LAKELAND BANCORP, INC.
                                             -----------------------------------

3.  I.R.S. or Social Security Number of Reporting Person
    (Voluntary) ###-##-####
               --------------

4.  Statement for Month/Year   12/99
                             ---------------------------------------------------

5.  If Amendment, Date of Original (Month/Year)   12/98
                                                --------------------------------

6.  Relationship of Reporting Person to Issuer (Check all applicable)

    [X] Director    [X] Officer             [ ] 10% Owner    [ ] Other
                        (give title below)                       (specify below)

        VICE PRESIDENT
        1.07
        --------------

- -------------------------------------------------------------------------------
Table I--Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

<TABLE>
<CAPTION>
- ------------------------------------------------------------------------------------------------------------------------------------
1. Title of Security         2. Trans-    3. Trans-     4. Securities Acquired (A)   5. Amount of        6. Owner-    7. Nature
   (Instr. 3)                   action       action        or Disposed of (D)           Securities          ship         of In-
                                Date         Code          (Instr. 3, 4 and 5)          Beneficially        Form:        direct
    LAKELAND BANCORP, INC.      (Month/      (Instr. 8)                                 Owned at the        Direct       Bene-
                                Day/                                                    end of              (D) or       ficial
                                Year)                                                   Issuer's            Indirect     Owner-
                                                                 (A) or                 Fiscal Year         (I)          ship
                                                        Amount   (D)        Price       (Instr. 3 and 4)    (Instr. 4)   (Instr. 4)
- ------------------------------------------------------------------------------------------------------------------------------------
<S>                          <C>          <C>           <C>      <C>      <C>        <C>                 <C>          <C>

- ------------------------------------------------------------------------------------------------------------------------------------
  COMMON                       2/15/99     DRP             63     A        19.00                             D            *1
- ------------------------------------------------------------------------------------------------------------------------------------
  "                            5/15/99     DRP             69     A        17.75                             D            *1
- ------------------------------------------------------------------------------------------------------------------------------------
  "                            8/16/99     G              168     A         N/K                              D            *1
- ------------------------------------------------------------------------------------------------------------------------------------
  "                           12/15/99     P               50     A         N/K                              D            *1
- ------------------------------------------------------------------------------------------------------------------------------------
  "                            7/15/99     J            5,652     A        15.50           107,792           D            *1
- ------------------------------------------------------------------------------------------------------------------------------------
  "                            2/15/99     DRP             64     A        19.00                             I            *2
- ------------------------------------------------------------------------------------------------------------------------------------
  "                            5/14/99     DRP             69     A        17.75                             I            *2
- ------------------------------------------------------------------------------------------------------------------------------------
  "                            8/19/99     DRP             82     A        14.87                             I            *2
- ------------------------------------------------------------------------------------------------------------------------------------
  "                           11/15/99     DRP             89     A        15.50            16,533           I            *2
- ------------------------------------------------------------------------------------------------------------------------------------
  "                            8/16/99     G              383     D         N/K                383           I            *3
- ------------------------------------------------------------------------------------------------------------------------------------
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
</TABLE>

<PAGE>

FORM 5 (continued)

 Table II--Derivative Securities Acquired, Disposed of, or Beneficially Owned
        (e.g., puts, calls, warrants, options, convertible securities)

<TABLE>
<CAPTION>
- -----------------------------------------------------------------------------------------------------------------------------
 1. Title of Derivative            2. Conver-          3. Trans-           4. Transac-            5. Number of Deriv-
    Security (Instr. 3)               sion or             action              tion Code              ative Securities
                                      Exercise            Date                (Instr. 8)             Acquired (A) or
                                      Price of            (Month/                                    Disposed of (D)
                                      Deriv-              Day/                                       (Instr. 3, 4, and 5)
                                      ative               Year)
                                      Security

                                                                                                   ---------------------------
                                                                                                         (A)         (D)

- -----------------------------------------------------------------------------------------------------------------------------
<S>                                <C>                 <C>                 <C>                    <C>            <C>

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------
<CAPTION>
- ------------------------------------------------------------------------------------------------------------------------------------
6. Date Exer-          7. Title and Amount of            8. Price         9. Number            10. Owner-         11. Na-
   cisable and            Underlying Securities             of               of Deriv-             ship               ture
   Expiration             (Instr. 3 and 4)                  Deriv-           ative                 of De-             of In-
   Date                                                     ative            Secur-                rivative           direct
   (Month/Day/                                              Secur-           ities                 Secu-              Bene-
   Year)                                                    ity              Bene-                 rity:              ficial
                                                            (Instr. 5)       ficially              Direct             Owner-
 --------------------------------------------                                Owned                 (D) or             ship
 Date          Expira-              Amount or                                at End                Indi-              (Instr. 4)
 Exer-         tion         Title   Number of                                of Year               rect (1)
 cisable       Date                 Shares                                   (Instr. 4)            (Instr. 4)

- ------------------------------------------------------------------------------------------------------------------------------------
<S>            <C>          <C>     <C>                   <C>              <C>                   <C>             <C>

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------
</TABLE>

Explanation of Responses:


            /s/ Bruce G. Bohuny              1-26-2000
       --------------------------------  -----------------
       **Signature of Reporting Person        Date

   **  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 provided is insufficient, see Instruction 6 for procedure.

<PAGE>

                                                /------------------------------/
                                                /        OMB APPROVAL          /
                                                /------------------------------/
                                                / OMB Number:        3235-0362 /
                                                / Expires:  February 1, 1994   /
                                                / Estimated average burden     /
                                                / hours per response...... 1.0 /
                                                /------------------------------/

+--------+                                        U.S.
| FORM 5 |        2 of 3           SECURITIES AND EXCHANGE COMMISSION
+--------+                                Washington, D.C. 20549

[_] Check box if
    no longer subject     ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
    to Section 16.
    Form 4 or Form 5       Filed pursuant to Section 16(a) of the Securities
    obligations may           Exchange Act of 1934, Section 17(a) of the
    continue. See            Public Utility Holding Company Act of 1935 or
    Instruction 1(b).      Section 30(f) of the Investment Company Act of 1940

[_] Form 3 Holdings Reported

[_] Form 4 Transactions Reported
- --------------------------------------------------------------------------------
1.  Name and Address of Reporting Person

         BOHUNY                      BRUCE                          G.
    ----------------------------------------------------------------------------
        (Last)                      (First)                        (Middle)

         C/O LAKELAND BANCORP, INC.
         250 OAK RIDGE ROAD
    ----------------------------------------------------------------------------
                                   (Street)

        OAK RIDGE,                   N.J.                              07438
    ----------------------------------------------------------------------------
        (City)                      (State)                           (Zip)


2.  Issuer Name and Ticker or Trading Symbol  LAKELAND BANCORP, INC.
                                             -----------------------------------

3.  I.R.S. or Social Security Number of Reporting Person
    (Voluntary)  ###-##-####
               --------------

4.  Statement for Month/Year   12/99
                             ---------------------------------------------------

5.  If Amendment, Date of Original (Month/Year)    12/98
                                                --------------------------------

6.  Relationship of Reporting Person to Issuer (Check all applicable)

    [X] Director    [X] Officer             [_] 10% Owner    [_] Other
                        (give title below)                       (specify below)

        VICE PRESIDENT
        1.07
        --------------

- -------------------------------------------------------------------------------
Table I--Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

<TABLE>
<CAPTION>
- ------------------------------------------------------------------------------------------------------------------------------------
1. Title of Security         2. Trans-    3. Trans-     4. Securities Acquired (A)   5. Amount of        6. Owner-    7. Nature
   (Instr. 3)                   action       action        or Disposed of (D)           Securities          ship         of In-
                                Date         Code          (Instr. 3, 4 and 5)          Beneficially        Form:        direct
    LAKELAND BANCORP, INC.      (Month/      (Instr. 8)                                 Owned at            Direct       Bene-
                                Day/                                                    End of              (D) or       ficial
                                Year)                                                   Issuer's            Indirect     Owner-
                                                                 (A) or                 Fiscal Year         (I)          ship
                                                        Amount   (D)        Price       (Instr. 3 and 4)    (Instr. 4)   (Instr. 4)
- ------------------------------------------------------------------------------------------------------------------------------------
<S>                          <C>          <C>           <C>      <C>      <C>        <C>                 <C>          <C>

- ------------------------------------------------------------------------------------------------------------------------------------
  COMMON                       12/31/98                                                     3,198              I            *4
- ------------------------------------------------------------------------------------------------------------------------------------
  "                             2/15/98      DRP             5      A      19.00                               I            *5
- ------------------------------------------------------------------------------------------------------------------------------------
  "                             5/14/99      DRP             6      A      17.75                               I            *5
- ------------------------------------------------------------------------------------------------------------------------------------
  "                             8/19/99      DRP             6      A      14.87                               I            *5
- ------------------------------------------------------------------------------------------------------------------------------------
  "                            11/15/99      DRP             7      A      13.85            1,257              I            *5
- ------------------------------------------------------------------------------------------------------------------------------------
  "                            12/31/99       T          8,251      D       N/K               0                I            *6
- ------------------------------------------------------------------------------------------------------------------------------------
  "                             2/15/99                      5      A      19.00                               I            *7
- ------------------------------------------------------------------------------------------------------------------------------------
  "                             5/14/99                      6      A      17.75                               I            *7
- ------------------------------------------------------------------------------------------------------------------------------------
  "                             8/19/99                      7      A      14.87                               I            *7
- ------------------------------------------------------------------------------------------------------------------------------------
  "                            11/15/99                      8      A      13.85            1,392              I            *7
- ------------------------------------------------------------------------------------------------------------------------------------
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
</TABLE>

<PAGE>

FORM 5 (continued)

 Table II--Derivative Securities Acquired, Disposed of, or Beneficially Owned
        (e.g., puts, calls, warrants, options, convertible securities)

<TABLE>
<CAPTION>
- -----------------------------------------------------------------------------------------------------------------------------
 1. Title of Derivative            2. Conver-          3. Trans-           4. Transac-            5. Number of Deriv-
    Security (Instr. 3)               sion or             action              tion Code              ative Securities
                                      Exercise            Date                (Instr. 8)             Acquired (A) or
                                      Price of            (Month/                                    Disposed of (D)
                                      Deriv-              Day/                                       (Instr. 3, 4, and 5)
                                      ative               Year)
                                      Security

                                                                                                   ---------------------------
                                                                                                         (A)         (D)

- -----------------------------------------------------------------------------------------------------------------------------
<S>                                <C>                 <C>                 <C>                    <C>    <C>         <C>

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------
</TABLE>


<TABLE>
<CAPTION>
- ------------------------------------------------------------------------------------------------------------------------------------
6. Date Exer-          7. Title and Amount of            8. Price         9. Number            10. Owner-         11. Na-
   cisable and            Underlying Securities             of               of Deriv-             ship               ture
   Expiration             (Instr. 3 and 4)                  Deriv-           ative                 of De-             of In-
   Date                                                     ative            Secur-                rivative           direct
   (Month/Day/                                              Secur-           ities                 Secu-              Bene-
   Year)                                                    ity              Bene-                 rity:              ficial
                                                            (Instr. 5)       ficially              Direct             Owner-
 --------------------------------------------                                Owned                 (D) or             ship
 Date          Expira-              Amount or                                at End                Indi-              (Instr. 4)
 Exer-         tion         Title   Number of                                of Year               rect (1)
 cisable       Date                 Shares                                   (Instr. 4)            (Instr. 4)

- ------------------------------------------------------------------------------------------------------------------------------------
<S>            <C>          <C>     <C>                  <C>              <C>                  <C>                <C>

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------
</TABLE>

Explanation of Responses:

*1   Owned solely by Bruce G. Bohuny
*2   Owned solely by Judy Bohuny, wife of Bruce G. Bohuny
*3   Owned by Est. of Emma Bohuny, Bruce G. Bohuny - executor
*4   Held by Merrill Lynch - Bruce G. Bohuny, owner
*5   Held in name of Brooks - Bruce G. Bohuny, owner
*6   Held in name of Bruce D. Bohuny, son of Bruce G. Bohuny
*7   Held in name of Zurick Group - Bruce G. Bohuny, partner

          /s/ Bruce G. Bohuny                1-26-2000
       --------------------------------  -----------------
       **Signature of Reporting Person        Date

   **  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 provided is insufficient, see Instruction 6 for procedure.

<PAGE>

                                                /------------------------------/
                                                /        OMB APPROVAL          /
                                                /------------------------------/
                                                / OMB Number:        3235-0362 /
                                                / Expires:  February 1, 1994   /
                                                / Estimated average burden     /
                                                / hours per response...... 1.0 /
                                                /------------------------------/

+--------+                                       U.S.
| FORM 5 |       3 of 3            SECURITIES AND EXCHANGE COMMISSION
+--------+                                Washington, D.C. 20549

[_] Check box if
    no longer subject     ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
    to Section 16.
    Form 4 or Form 5       Filed pursuant to Section 16(a) of the Securities
    obligations may           Exchange Act of 1934, Section 17(a) of the
    continue. See            Public Utility Holding Company Act of 1935 or
    Instruction 1(b).      Section 30(f) of the Investment Company Act of 1940

[_] Form 3 Holdings Reported

[_] Form 4 Transactions Reported
- --------------------------------------------------------------------------------
1.  Name and Address of Reporting Person

         BOHUNY                      BRUCE                          G.
    ----------------------------------------------------------------------------
        (Last)                      (First)                        (Middle)

         C/O LAKELAND BANCORP, INC.
         250 OAK RIDGE ROAD
    ----------------------------------------------------------------------------
                                   (Street)

         OAK RIDGE,                  N.J.                              07438
    ----------------------------------------------------------------------------
        (City)                      (State)                           (Zip)


2.  Issuer Name and Ticker or Trading Symbol   LAKELAND BANCORP, INC.
                                             -----------------------------------

3.  I.R.S. or Social Security Number of Reporting Person (Voluntary) ###-##-####
                                                                     -----------

4.  Statement for Month/Year   12/99
                             ---------------------------------------------------

5.  If Amendment, Date of Original (Month/Year)   12/98
                                                --------------------------------

6.  Relationship of Reporting Person to Issuer (Check all applicable)

    [X] Director    [X] Officer             [_] 10% Owner    [_] Other
                        (give title below)                       (specify below)

     VICE PRESIDENT
     1.07
     --------------

- -------------------------------------------------------------------------------
Table I--Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

<TABLE>
<CAPTION>
- ------------------------------------------------------------------------------------------------------------------------------------
1. Title of Security         2. Trans-    3. Trans-     4. Securities Acquired (A)   5. Amount of        6. Owner-    7. Nature
   (Instr. 3)                   action       action        or Disposed of (D)           Securities          ship         of In-
                                Date         Code          (Instr. 3, 4 and 5)          Beneficially        Form:        direct
                                (Month/      (Instr. 8)                                 Owned at            Direct       Bene-
    LAKELAND BANCORP, INC.      Day/                                                    End of              (D) or       ficial
                                Year)                                                   Issuer's            Indirect     Owner-
                                                                 (A) or                 Fiscal Year         (I)          ship
                                                        Amount   (D)        Price       (Instr. 3 and 4)    (Instr. 4)   (Instr. 4)
- ------------------------------------------------------------------------------------------------------------------------------------
<S>                          <C>          <C>           <C>      <C>      <C>        <C>                 <C>          <C>

- ------------------------------------------------------------------------------------------------------------------------------------
  COMMON                       7/15/99        J           5200       A      15.50          5200               I             *8
- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly
</TABLE>
<PAGE>

FORM 5 (continued)

 Table II--Derivative Securities Acquired, Disposed of, or Beneficially Owned
        (e.g., puts, calls, warrants, options, convertible securities)

<TABLE>
<CAPTION>
- -----------------------------------------------------------------------------------------------------------------------------
 1. Title of Derivative            2. Conver-          3. Trans-           4. Transac-            5. Number of Deriv-
    Security (Instr. 3)               sion or             action              tion Code              ative Securities
                                      Exercise            Date                (Instr. 8)             Acquired (A) or
                                      Price of            (Month/                                    Disposed of (D)
                                      Deriv-              Day/                                       (Instr. 3, 4, and 5)
                                      ative               Year)
                                      Security

                                                                                                   ---------------------------
                                                                                                         (A)         (D)

- -----------------------------------------------------------------------------------------------------------------------------
<S>                                <C>                 <C>                 <C>                    <C>                <C>

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------

- -----------------------------------------------------------------------------------------------------------------------------
</TABLE>


<TABLE>
<CAPTION>
- ------------------------------------------------------------------------------------------------------------------------------------
6. Date Exer-          7. Title and Amount of            8. Price         9. Number            10. Owner-         11. Na-
   cisable and            Underlying Securities             of               of Deriv-             ship               ture
   Expiration             (Instr. 3 and 4)                  Deriv-           ative                 of De-             of In-
   Date                                                     ative            Secur-                rivative           direct
   (Month/Day/                                              Secur-           ities                 Secu-              Bene-
   Year)                                                    ity              Bene-                 rity:              ficial
                                                            (Instr. 5)       ficially              Direct             Owner-
 --------------------------------------------                                Owned                 (D) or             ship
 Date          Expira-              Amount or                                at End                Indi-              (Instr. 4)
 Exer-         tion         Title   Number of                                of Year               rect (1)
 cisable       Date                 Shares                                   (Instr. 4)            (Instr. 4)

- ------------------------------------------------------------------------------------------------------------------------------------
<S>            <C>     <C>          <C>                  <C>              <C>                  <C>                <C>

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------

- ------------------------------------------------------------------------------------------------------------------------------------
</TABLE>

Explanation of Responses:

G   - Gift
DRP - Dividend Reinvestment Plan
P   - Purchase
J   - Acquired through merger of High Point with Lakeland Bancorp

          /s/ Bruce G. Bohuny                1-26-2000
       --------------------------------  -----------------
       **Signature of Reporting Person        Date

   **  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 provided is insufficient, see Instruction 6 for procedure.



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