UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
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 control number. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
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) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Sample Gwendolyn G 3512 E. SILVER SPRINGS BLVD - #243 OCALA, FL 34470 |
 |  |  | None |
/s/ Gwendolyn G. Sample by Steven L. Sample, PoA | 06/26/2012 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 5(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). |
 Remarks: Following gifting of shares by the Reporting Person on September 28, 2010, the Reporting Person no longer is a 10% owner of the issued and outstanding shares of the Corporation, and is not a director or officer of the Corporation. Reporting Person disclaims any beneficial ownership in securities held by others, and disclaims beneficial ownership of any person in her securities. Unless the Reporting Person should hereafter acquire a significant number of securities of the Corporation, Reporting Person  will no longer be responsible to report transaction on Forms 3 or 4. |