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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549ANNUAL STATEMENT OF CHANGES IN 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. | 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. | SEC 2270 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
MUHLEISEN ANGIE C/O FARMERS & MERCHANTS INVESTMENT, INC. 6801 SOUTH 27TH STREET LINCOLN, NE 68512 |
 |  X |  |  |
/William J. Munn, Attorney-in-Fact for Angie Muhleisen/ | 02/08/2005 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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). |
(1) | The gift reported in this Form 5 was effected pursuant to a Rule 10b5-1 trading plan. |
(2) | Reporting person directly owns 1,155,143 shares of Class A Common Stock (including 88,864 shares held jointly with spouse) and is deemed to be the indirect beneficial owner of the following shares of Class A Common Stock: 11,068,604 shares held by Packers Service Group, Inc. ("Packers"); 4,500 shares held by Farmers & Merchants Investment, Inc. ("Farmers"); 795,521 shares held by the Angela L. Muhleisen Grantor Retained Annuity Trust ("GRAT"); 795,521 shares held by the Daniel D. Muhleisen GRAT; and 905,479 shares held by her spouse. The reporting person disclaims beneficial ownership of the securities held by Packers and Farmers except to the extent of her pecuniary interest in the holders thereof, and this report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. |