SEC FORM
3
SEC Form 3
FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
|
OMB APPROVAL |
OMB Number: |
3235-0104 |
Estimated average burden |
hours per response: |
0.5 |
|
|
1. Name and Address of Reporting Person*
2277 FAIR OAKS BOULEVARD, SUITE 440 |
|
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year) 09/01/2004
|
3. Issuer Name and Ticker or Trading Symbol
MOLINA HEALTHCARE INC
[ MOH ]
|
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
X |
Officer (give title below) |
|
Other (specify below) |
CEO of Molina of California |
|
5. If Amendment, Date of Original Filed
(Month/Day/Year)
|
6. Individual or Joint/Group Filing (Check Applicable Line)
X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting Person |
|
Table I - Non-Derivative Securities Beneficially Owned |
1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
|
3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
|
4. Nature of Indirect Beneficial Ownership (Instr.
5)
|
Common Stock |
474 |
D |
|
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
|
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: Direct (D) or Indirect (I) (Instr.
5)
|
6. Nature of Indirect Beneficial Ownership (Instr.
5)
|
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Explanation of Responses: |
|
Joann Zarza-Garrido, by Jeff D. Barlow, Attorney-in-Fact. |
09/03/2004 |
|
** Signature of Reporting Person |
Date |
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
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). |
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
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 Number. |
rrd43303_48829.html
LIMITED POWER OF ATTORNEY FOR SECTION 16(a) FILINGS
Know all by these presents, that the undersigned hereby
constitutes and appoints Mark L. Andrews and Jeff D. Barlow,
and each acting singly, the undersigned's true and lawful
attorney-in-fact to:
1) execute for and on behalf of the undersigned, in the
undersigned's capacity as an officer, director and/or
stockholder of Molina Healthcare, Inc. (the 'Company'),
Forms ID, 3, 4, and 5 and amendments thereto in accordance
with Section 16(a) of the Securities Exchange Act of 1934
and the rules thereunder; and
2) do and perform any and all acts for and on behalf of
the undersigned which may be necessary or desirable to
complete and execute any such Form ID, 3, 4, or 5
or amendment thereto and timely file such form with the
United States Securities and Exchange Commission (the 'SEC')
and any stock exchange or similar authority.
The undersigned hereby grants to each such attorney-in-fact
full power and authority to do and perform any and every act
and thing whatsoever requisite, necessary, or proper to be done
in the exercise of any of the rights and powers herein granted,
as fully to all intents and purposes as the undersigned might or
could do if personally present, with full power of substitution
or revocation, hereby ratifying and confirming all that such
attorney-in-fact, or such attorney-in-fact's substitute or substitutes,
shall lawfully do or cause to be done by virtue of this Power of
Attorney and the rights and powers herein granted. The undersigned
acknowledges that the foregoing attorneys-in-fact, in serving in
such capacity at the request of the undersigned, are not assuming,
nor is the Company assuming, any of the undersigned's responsibilities
to comply with Section 16 of the Securities Exchange Act of 1934.
This Power of Attorney shall remain in full force and effect until
the undersigned is no longer required to file Forms ID, 3, 4, and
5 with respect to the undersigned's holdings of and transaction
in securities of the Company, unless earlier revoked by the undersigned
in a signed writing delivered to the foregoing attorneys-in-fact.
This Power of Attorney may be filed with the SEC as a confirming
statement of the authority granted herein.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney
to be executed as of this 18th day of August, 2004.
/s/ Joann Zarza-Garrido
Signature
Joann Zarza-Garrido
Printed Name
Exhibit 24.1