SOUTHWESTERN LIFE HOLDINGS INC
4, 2000-11-13
LIFE INSURANCE
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                                     FORM 4



                     U.S. SECURITIES AND EXCHANGE COMMISSION
                             Washington, D.C. 20549

                  STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

                       Filed pursuant to Section 16(a) of
                         the Securities Exchange Act of
                           1934, Section 17(a) of the
                   Public Utility Holding Company Act of 1935
             or Section 30(f) of the Investment Company Act of 1940


/  / 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*:

         Vicuna Advisors LLC

         ------------------------------
         (LAST)        (FIRST)   (MIDDLE)

         230 Park Avenue
         7th Floor
         Attn:  Kenneth F. Cooper

         -------------------------------------------
         (STREET)

         New York,       New York          10169

         ------------------------------------------
         (CITY)        (STATE)           (ZIP)



2.   Issuer Name and Ticker or Trading Symbol:

         Southwestern Life Holdings, Inc. (SWLH)

3.   IRS Identification Number of Reporting Person, if an entity  (Voluntary):

         13-4006560


<PAGE>


4.   Statement for Month/Year:

         10/2000

5.   If Amendment, Date of Original:

      (Month/Year)



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

         _____  Director

         _____  Officer (give title below)

         __X__  10% Owner

         _____  Other (specify below)

7.   Individual or Joint/Group Filing (Check Applicable Line)

         _____  Form filed by One Reporting Person

         __X__  Form filed by More than One Reporting Person



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



1.   Title of Security:

      (Instr. 3)

         Common Stock, par value $.01 ("Common Stock")
         Common Stock
         Common Stock
         Common Stock
         Common Stock
         Common Stock
         Common Stock

2.   Transaction Date:

      (Month/Day/Year)

         10/4/2000




                                       2
<PAGE>


         10/5/2000
         10/9/2000
         10/11/2000
         10/12/2000
         10/13/2000
         10/18/2000

3.   Transaction Code:

      (Instr. 8)

      Code                 V

         P
         P
         P
         P
         P
         P
         P

4.   Securities Acquired (A) or Disposed of (D):

      (Instr. 3, 4 and 5)

    Amount               (A) or (D)             Price
       46,000                A                $12.2500
        5,730                A                $12.3750
        5,000                A                $12.3125
       20,000                A                $12.0938
       32,700                A                $11.9654
        3,600                A                $12.0625
        3,700                A                $12.4375


5.   Amount of Securities Beneficially Owned at End of Month:

      (Instr. 3 and 4)

         1,240,000

6.   Ownership Form:   Direct (D) or Indirect (I):

      (Instr. 4)

         I
         I




                                       3
<PAGE>


         I
         I
         I
         I
         I

7.   Nature of Indirect Beneficial Ownership:

      (Instr. 4)

     As investment adviser to Vicuna Capital I, L.P. and WNP Investment
     Partnership, L.P.

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).



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



1.   Title of Derivative Security:

      (Instr. 3)



2.   Conversion or Exercise Price of Derivative Security:



3.   Transaction Date:

      (Month/Day/Year)



4.   Transaction Code:

      (Instr. 8)

      Code        V




                                       4
<PAGE>


5.   Number of Derivative Securities Acquired (A) or Disposed of (D):

      (Instr. 3, 4 and 5)

                    (A)                 (D)



6.    Date Exercisable and Expiration Date:

       (Month/Day/Year)



         Date Exercisable                      Expiration Date



7.   Title and Amount of Underlying Securities:

       (Instr. 3 and 4)

      Title                Amount or Number of Shares



8.   Price of Derivative Security:

      (Instr. 5)



9.   Number of Derivative Securities Beneficially Owned at End of Month:

      (Instr. 4)



10.  Ownership Form of Derivative Security:   Direct (D) or Indirect (I):

       (Instr. 4)



11.  Nature of Indirect Beneficial Ownership:

       (Instr. 4)




                                       5
<PAGE>


Explanation of Responses:

              This Form 4 is being filed jointly by Vicuna Advisors LLC
         ("Advisors"), a Delaware limited liability company, Vicuna Partners
         LLC, a Delaware limited liability company ("Partners"), Vicuna Capital
         I, L.P., a Delaware limited partnership ("Capital"), WNP Investment
         Partnership, a Delaware limited partnership ("WNP"), and Joshua G.
         Welch (collectively, the "Reporting Persons"). Capital and WNP are
         private partnerships organized to make investments in securities.
         Advisors is the investment adviser to Capital and WNP and Partners is
         the general partner of Capital and WNP. Welch is the Managing Member of
         Advisors and Partners. Advisors is the designated filer.

              The filing of this statement is not an admission by any Reporting
         Person that such Reporting Person and any other Reporting Person or any
         other person constitute a "group" for purposes of Section 13(d)(3) of
         the Securities Exchange Act of 1934, as amended, or Rule 13d-5
         thereunder or that any Reporting Person is the beneficial owner of any
         securities owned by any other Reporting Person or any other person.



[Signatures follow all attachments]














                                       6
<PAGE>


                   Attachment To Form 4 of Vicuna Advisors LLC
              in Respect of Southwestern Life Holdings, Inc. (SWLH)
                             Statement for: 10/2000


         This Form 4 is being filed jointly by Vicuna Advisors LLC ("Advisors"),
a Delaware limited liability company, Vicuna Partners LLC, a Delaware limited
liability company ("Partners"), Vicuna Capital I, L.P., a Delaware limited
liability company ("Capital"), WNP Investment Partnership, a Delaware limited
partnership ("WNP"), and Joshua G. Welch (collectively, the "Reporting
Persons"). Advisors is the designated filer.

Joint Filer Information

1.   Name and Address of Reporting Person*:

         Vicuna Partners LLC

         ------------------------------------------
         (LAST)        (FIRST)   (MIDDLE)

         230 Park Avenue
         7th Floor
         Attn:  Kenneth F. Cooper

         -------------------------------------------
         (STREET)

         New York,       New York          10169

         ------------------------------------------
         (CITY)        (STATE)           (ZIP)

2.   Issuer Name and Ticker or Trading Symbol:

         Southwestern Life Holdings, Inc. (SWLH)

3.   IRS Identification Number of Reporting Person, if an entity  (Voluntary):

         13-4006612

4.   Statement for Month/Year:

         10/2000

5.   If Amendment, Date of Original:

      (Month/Year)




                                       7
<PAGE>


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

         _____  Director

         _____  Officer (give title below)

         __X__  10% Owner

         _____  Other (specify below)

7.   Individual or Joint/Group Filing (Check Applicable Line)

         _____  Form filed by One Reporting Person

         __X__  Form filed by More than One Reporting Person



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



1.   Title of Security:

      (Instr. 3)

         Common Stock, par value $.01 ("Common Stock")
         Common Stock
         Common Stock
         Common Stock
         Common Stock
         Common Stock
         Common Stock

2.   Transaction Date:

      (Month/Day/Year)

         10/4/2000
         10/5/2000
         10/9/2000
         10/11/2000
         10/12/2000
         10/13/2000
         10/18/2000




                                       8
<PAGE>


3.   Transaction Code:

      (Instr. 8)

      Code                 V

         P
         P
         P
         P
         P
         P
         P

4.   Securities Acquired (A) or Disposed of (D):

      (Instr. 3, 4 and 5)

    Amount               (A) or (D)             Price
       46,000                A                $12.2500
        5,730                A                $12.3750
        5,000                A                $12.3125
       20,000                A                $12.0938
       32,700                A                $11.9654
        3,600                A                $12.0625
        3,700                A                $12.4375


5.   Amount of Securities Beneficially Owned at End of Month:

      (Instr. 3 and 4)

         1,240,000

6.   Ownership Form:   Direct (D) or Indirect (I):

      (Instr. 4)

         I
         I
         I
         I
         I
         I
         I




                                       9
<PAGE>


7.   Nature of Indirect Beneficial Ownership:

      (Instr. 4)

     As general partners of Vicuna Capital I, L.P. and WNP Investment
     Partnership, L.P.

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).



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



1.   Title of Derivative Security:

      (Instr. 3)



2.   Conversion or Exercise Price of Derivative Security:



3.   Transaction Date:

      (Month/Day/Year)



4.   Transaction Code:

      (Instr. 8)

      Code        V



5.   Number of Derivative Securities Acquired (A) or Disposed of (D):

      (Instr. 3, 4 and 5)

                    (A)                 (D)




                                       10
<PAGE>


6.    Date Exercisable and Expiration Date:

       (Month/Day/Year)



         Date Exercisable                      Expiration Date



7.   Title and Amount of Underlying Securities:

       (Instr. 3 and 4)

      Title                Amount or Number of Shares



8.   Price of Derivative Security:

      (Instr. 5)



9.   Number of Derivative Securities Beneficially Owned at End of Month:

      (Instr. 4)



10.  Ownership Form of Derivative Security:   Direct (D) or Indirect (I):

       (Instr. 4)



11.  Nature of Indirect Beneficial Ownership:

       (Instr. 4)



Explanation of Responses:

See Explanation of Responses to Form 4 of Advisors.

[Signatures follow all attachments]




                                       11
<PAGE>


                   Attachment To Form 4 of Vicuna Advisors LLC
              in Respect of Southwestern Life Holdings, Inc. (SWLH)
                             Statement for: 10/2000


         This Form 4 is being filed jointly by Vicuna Advisors LLC ("Advisors"),
a Delaware limited liability company, Vicuna Partners LLC, a Delaware limited
liability company ("Partners"), Vicuna Capital I, L.P., a Delaware limited
liability company ("Capital"), WNP Investment Partnership, a Delaware limited
partnership ("WNP"), and Joshua G. Welch (collectively, the "Reporting
Persons"). Advisors is the designated filer.

Joint Filer Information



1.   Name and Address of Reporting Person*:

         Vicuna Capital I, L.P.

         ------------------------------------------
         (LAST)        (FIRST)   (MIDDLE)

         230 Park Avenue
         7th Floor
         Attn:  Kenneth F. Cooper

         -------------------------------------------
         (STREET)

         New York,       New York          10169

         ------------------------------------------
         (CITY)        (STATE)           (ZIP)



2.   Issuer Name and Ticker or Trading Symbol:

         Southwestern Life Holdings, Inc. (SWLH)



3.   IRS Identification Number of Reporting Person, if an entity  (Voluntary):

         13-4006625



4.   Statement for Month/Year:

         10/2000



5.   If Amendment, Date of Original:

      (Month/Year)




                                       12
<PAGE>


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

         _____  Director

         _____  Officer (give title below)

         __X__  10% Owner

         _____  Other (specify below)

7.   Individual or Joint/Group Filing (Check Applicable Line)

         _____  Form filed by One Reporting Person

         __X__  Form filed by More than One Reporting Person



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



1.   Title of Security:

      (Instr. 3)

         Common Stock, par value $.01 ("Common Stock")
         Common Stock
         Common Stock
         Common Stock
         Common Stock
         Common Stock
         Common Stock



2.   Transaction Date:

      (Month/Day/Year)

         10/4/2000
         10/5/2000
         10/9/2000
         10/11/2000
         10/12/2000
         10/13/2000
         10/18/2000




                                       13
<PAGE>



3.   Transaction Code:

      (Instr. 8)

      Code                 V

         P
         P
         P
         P
         P
         P
         P



4.   Securities Acquired (A) or Disposed of (D):

      (Instr. 3, 4 and 5)


       Amount           (A) or (D)             Price

       34,900                A                $12.2500
        4,350                A                $12.3750
        3,800                A                $12.3125
       15,200                A                $12.0938
       24,800                A                $11.9654
        2,700                A                $12.0625
        2,800                A                $12.4375



5.   Amount of Securities Beneficially Owned at End of Month:

      (Instr. 3 and 4)

         988,970



6.   Ownership Form:   Direct (D) or Indirect (I):

      (Instr. 4)

         D
         D
         D
         D
         D
         D
         D




                                       14
<PAGE>


7.   Nature of Indirect Beneficial Ownership:

      (Instr. 4)



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).



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



1.   Title of Derivative Security:

      (Instr. 3)



2.   Conversion or Exercise Price of Derivative Security:



3.   Transaction Date:

      (Month/Day/Year)



4.   Transaction Code:

      (Instr. 8)

      Code        V



5.   Number of Derivative Securities Acquired (A) or Disposed of (D):

      (Instr. 3, 4 and 5)

                    (A)                 (D)




                                       15
<PAGE>


6.    Date Exercisable and Expiration Date:

       (Month/Day/Year)



         Date Exercisable                     Expiration Date



7.   Title and Amount of Underlying Securities:

       (Instr. 3 and 4)

      Title                Amount or Number of Shares



8.   Price of Derivative Security:

      (Instr. 5)



9.   Number of Derivative Securities Beneficially Owned at End of Month:

      (Instr. 4)



10.  Ownership Form of Derivative Security:   Direct (D) or Indirect (I):

       (Instr. 4)



11.  Nature of Indirect Beneficial Ownership:

       (Instr. 4)



Explanation of Responses:

See Explanation of Responses to Form 4 of Advisors.

[Signatures follow all attachments]




                                       16


<PAGE>


                   Attachment To Form 4 of Vicuna Advisors LLC
              in Respect of Southwestern Life Holdings, Inc. (SWLH)
                             Statement for: 10/2000


         This Form 4 is being filed jointly by Vicuna Advisors LLC ("Advisors"),
a Delaware limited liability company, Vicuna Partners LLC, a Delaware limited
liability company ("Partners"), Vicuna Capital I, L.P., a Delaware limited
liability company ("Capital"), WNP Investment Partnership, a Delaware limited
partnership ("WNP"), and Joshua G. Welch (collectively, the "Reporting
Persons"). Advisors is the designated filer.


Joint Filer Information



1.   Name and Address of Reporting Person*:

         WNP Investment Partnership, L.P.

         ------------------------------------------
         (LAST)        (FIRST)   (MIDDLE)

         230 Park Avenue
         7th Floor
         Attn:  Kenneth F. Cooper

         -------------------------------------------
         (STREET)

         New York,       New York          10169

         ------------------------------------------
         (CITY)        (STATE)           (ZIP)



2.   Issuer Name and Ticker or Trading Symbol:

         Southwestern Life Holdings, Inc. (SWLH)



3.   IRS Identification Number of Reporting Person, if an entity  (Voluntary):

         13-4006626



4.   Statement for Month/Year:

         10/2000



5.   If Amendment, Date of Original:

      (Month/Year)




                                       17
<PAGE>


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

         _____  Director

         _____  Officer (give title below)

         __X__  10% Owner

         _____  Other (specify below)

7.   Individual or Joint/Group Filing (Check Applicable Line)

         _____  Form filed by One Reporting Person

         __X__  Form filed by More than One Reporting Person



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



1.   Title of Security:

      (Instr. 3)

         Common Stock, par value $.01 ("Common Stock")
         Common Stock
         Common Stock
         Common Stock
         Common Stock
         Common Stock
         Common Stock

2.   Transaction Date:

      (Month/Day/Year)

         10/4/2000
         10/5/2000
         10/9/2000
         10/11/2000
         10/12/2000
         10/13/2000
         10/18/2000




                                       18
<PAGE>


3.   Transaction Code:

      (Instr. 8)

      Code                 V

         P
         P
         P
         P
         P
         P
         P



4.   Securities Acquired (A) or Disposed of (D):

      (Instr. 3, 4 and 5)

       Amount            (A) or (D)             Price

       11,100                A                $12.2500
        1,380                A                $12.3750
        1,200                A                $12.3125
        4,800                A                $12.0938
        7,900                A                $11.9654
          900                A                $12.0625
          900                A                $12.4375



5.   Amount of Securities Beneficially Owned at End of Month:

      (Instr. 3 and 4)

         251,030



6.   Ownership Form:   Direct (D) or Indirect (I):

      (Instr. 4)

         D
         D
         D
         D
         D
         D
         D




                                       19
<PAGE>


7.   Nature of Indirect Beneficial Ownership:

      (Instr. 4)



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).



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



1.   Title of Derivative Security:

      (Instr. 3)



2.   Conversion or Exercise Price of Derivative Security:



3.   Transaction Date:

      (Month/Day/Year)



4.   Transaction Code:

      (Instr. 8)

      Code        V



5.   Number of Derivative Securities Acquired (A) or Disposed of (D):

      (Instr. 3, 4 and 5)

                 (A)                 (D)




                                       20
<PAGE>


6.    Date Exercisable and Expiration Date:

       (Month/Day/Year)



         Date Exercisable                       Expiration Date



7.   Title and Amount of Underlying Securities:

       (Instr. 3 and 4)

      Title                Amount or Number of Shares



8.   Price of Derivative Security:

      (Instr. 5)



9.   Number of Derivative Securities Beneficially Owned at End of Month:

      (Instr. 4)



10.  Ownership Form of Derivative Security:   Direct (D) or Indirect (I):

       (Instr. 4)



11.  Nature of Indirect Beneficial Ownership:

       (Instr. 4)



Explanation of Responses:

         See Explanation of Responses to Form 4 of Advisors.

[Signatures follow all attachments]




                                       21
<PAGE>



                   Attachment To Form 4 of Vicuna Advisors LLC
              in Respect of Southwestern Life Holdings, Inc. (SWLH)
                             Statement for: 10/2000


         This Form 4 is being filed jointly by Vicuna Advisors LLC ("Advisors"),
a Delaware limited liability company, Vicuna Partners LLC, a Delaware limited
liability company ("Partners"), Vicuna Capital I, L.P., a Delaware limited
liability company ("Capital"), WNP Investment Partnership, a Delaware limited
partnership ("WNP"), and Joshua G. Welch (collectively, the "Reporting
Persons"). Advisors is the designated filer.


Joint Filer Information


1.   Name and Address of Reporting Person*:

         Joshua G. Welch

         ------------------------------------------
         (LAST)        (FIRST)   (MIDDLE)

         230 Park Avenue
         7th Floor

         -------------------------------------------
         (STREET)

         New York,       New York          10169

         ------------------------------------------
         (CITY)        (STATE)           (ZIP)


2.   Issuer Name and Ticker or Trading Symbol:

         Southwestern Life Holdings, Inc. (SWLH)


3.   IRS Identification Number of Reporting Person, if an entity  (Voluntary):


4.   Statement for Month/Year:

         10/2000


5.   If Amendment, Date of Original:

      (Month/Year)


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

         _____  Director




                                       22
<PAGE>


         _____  Officer (give title below)

         __X__  10% Owner

         _____  Other (specify below)

7.   Individual or Joint/Group Filing (Check Applicable Line)

         _____  Form filed by One Reporting Person

         __X__  Form filed by More than One Reporting Person



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

1.   Title of Security:

      (Instr. 3)

         Common Stock, par value $.01 ("Common Stock")
         Common Stock
         Common Stock
         Common Stock
         Common Stock
         Common Stock
         Common Stock

2.   Transaction Date:

      (Month/Day/Year)

         10/4/2000
         10/5/2000
         10/9/2000
         10/11/2000
         10/12/2000
         10/13/2000
         10/18/2000

3.   Transaction Code:

      (Instr. 8)

      Code                 V

         P
         P




                                       23
<PAGE>


         P
         P
         P
         P
         P


4.   Securities Acquired (A) or Disposed of (D):

      (Instr. 3, 4 and 5)

    Amount               (A) or (D)             Price
       46,000                A                $12.2500
        5,730                A                $12.3750
        5,000                A                $12.3125
       20,000                A                $12.0938
       32,700                A                $11.9654
        3,600                A                $12.0625
        3,700                A                $12.4375


5.   Amount of Securities Beneficially Owned at End of Month:

      (Instr. 3 and 4)

         1,240,000


6.   Ownership Form:   Direct (D) or Indirect (I):

      (Instr. 4)

         I
         I
         I
         I
         I
         I
         I


7.   Nature of Indirect Beneficial Ownership:

      (Instr. 4)

         As managing member of Vicuna Advisors LLC and Vicuna Partners LLC.

Reminder:      Report on a separate line for each class of securities
               beneficially owned directly or indirectly.




                                       24
<PAGE>


*  If the form is  filed by more  than one  reporting  person,  see  Instruction
   4(b)(v).



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



1.   Title of Derivative Security:

      (Instr. 3)



2.   Conversion or Exercise Price of Derivative Security:



3.   Transaction Date:

      (Month/Day/Year)



4.   Transaction Code:

      (Instr. 8)

      Code        V



5.   Number of Derivative Securities Acquired (A) or Disposed of (D):

      (Instr. 3, 4 and 5)

                    (A)                 (D)



6.    Date Exercisable and Expiration Date:

       (Month/Day/Year)



             Date Exercisable                   Expiration Date




                                       25
<PAGE>


7.   Title and Amount of Underlying Securities:

       (Instr. 3 and 4)

      Title                Amount or Number of Shares



8.   Price of Derivative Security:

      (Instr. 5)



9.   Number of Derivative Securities Beneficially Owned at End of Month:

      (Instr. 4)



10.  Ownership Form of Derivative Security:   Direct (D) or Indirect (I):

       (Instr. 4)



11.  Nature of Indirect Beneficial Ownership:

       (Instr. 4)



Explanation of Responses:

         See Explanation of Responses to Form 4 of Advisors.



[Signatures follow all attachments]













                                       26
<PAGE>


                                    SIGNATURE
                                    ---------


                                            VICUNA ADVISORS LLC


                                            By: /s/ Joshua G. Welch
                                               --------------------------------
                                                Joshua G. Welch
                                                Managing Member


                                            VICUNA PARTNERS LLC


                                            By: /s/ Joshua G. Welch
                                               --------------------------------
                                                Joshua G. Welch
                                                Managing Member

                                            VICUNA CAPITAL I, L.P.
                                            By:  Vicuna Partners LLC, General
                                                   Partner

                                            By: /s/ Joshua G. Welch
                                               --------------------------------
                                                Joshua G. Welch
                                                Managing Member

                                            WNP INVESTMENT PARTNERSHIP, L.P.
                                            By:  Vicuna Partners LLC, General
                                                   Partner

                                            By: /s/ Joshua G. Welch
                                               --------------------------------
                                                Joshua G. Welch
                                                Managing Member


                                                /s/ Joshua G. Welch
                                           ------------------------------------
                                                Joshua G. Welch


Date:  November 10, 2000

** 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 the Form, one of which must be manually signed. If
space provided is insufficient, see Instruction 6 for procedure.

Potential persons who are to respond to the collection of information contained
in this form are not required to respond unless the form displays a currently
valid OMB Number.





                                       27


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