-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, T148oJLrG9apM99luYtm903R85uCVD4fMChhSZJN+2AACpY/QmaA6GyK88ItE3zg LcmyMHDiORAQDc22uzTenA== 0000950152-02-006470.txt : 20020815 0000950152-02-006470.hdr.sgml : 20020815 20020815114141 ACCESSION NUMBER: 0000950152-02-006470 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20020630 FILED AS OF DATE: 20020815 COMPANY DATA: COMPANY CONFORMED NAME: OSBORNE RICHARD L CENTRAL INDEX KEY: 0001180433 DIRECTOR FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 3201 ENTERPRISE PARKWAY STREET 2: SUITE 220 CITY: BEACHWOOD STATE: OH ZIP: 44122 BUSINESS PHONE: 2165143350 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: NCS HEALTHCARE INC CENTRAL INDEX KEY: 0001004990 STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-DRUG STORES AND PROPRIETARY STORES [5912] IRS NUMBER: 341816187 STATE OF INCORPORATION: DE FISCAL YEAR END: 0630 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-27602 FILM NUMBER: 02739200 BUSINESS ADDRESS: STREET 1: 3201 ENTERPRISE PKWY STREET 2: STE 2200 CITY: BEACHWOOD STATE: OH ZIP: 44122 BUSINESS PHONE: 2165143350 MAIL ADDRESS: STREET 1: 1400 MCDONALD INVESTMENT CENTER STREET 2: 800 SUPERIOR AVE CITY: CLEVELAND STATE: OH ZIP: 44114 5 1 l95878ae5.txt NCS HEALTHCARE/RICHARD OSBORNE FORM 5
U.S. SECURITIES AND EXCHANGE COMMISSION FORM 5 Washington, D.C. 20549 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP [ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) [ ] Form 3 Holdings Reported of the Public Utility Holding Company Act of 1935 or Section 30(f) [ ] Form 4 Transactions Reported of the Investment Company Act of 1940 - ------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person(*) 2. Issuer Name and Ticker or Trading Symbol NCS HealthCare, Inc. (NCSS) Osborne Richard L. - ------------------------------------------------------------------------------------------------------------------------ (Last) (First) (Middle) 3. IRS or Social Security 4. Statement for Number of Reporting Person (Voluntary) June 2002 3201 Enterprise Parkway, Suite 220 - ------------------------------------------------------------- --------------------------- (Street) 5. If Amendment, Date of Original (Month/Year) Beachwood Ohio 44122 - ------------------------------------------------------------------------------------------------------------------------ (City) (State) (Zip) 6. Relationship of Reporting Person to Issuer (Check all applicable) x Director 10% Owner --- --- Officer Other (specify --- --- below) - ----------------------------------------------------------- 7. Individual or Joint/Group Filing (Check applicable line) x Form Filed by one Reporting Person - ---- Form Filed by more than one Reporting Person - ---- - ------------------------------------------------------------------------------------------------------------------------------------ TABLE 1 - NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of 2. Transaction 3. Transaction 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature of Security Date Code or Disposed of (D) Securities Form: Indirect (Instr. 3) (Instr. 8) (Instr. 3, 4 and 5) Beneficially Direct (D) or Beneficial Owned at End Indirect (I) Ownership (Month/Day/ Amount (A) or Price of Issuer's (Instr. 3) (Instr. 4) Year) (D) Fiscal Year (Instr. 3 and 4) - ------------------------------------------------------------------------------------------------------------------------------------ Class A Common Stock 49,657 (1) D - ------------------------------------------------------------------------------------------------------------------------------------ Class B Common Stock 101,403 (1) D - ------------------------------------------------------------------------------------------------------------------------------------ (*) If the form is filed by more than one Reporting Person, see Instruction 4(b)(v). Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over) (Print or Type Responses)
FORM 5 (CONTINUED) TABLE II - DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) 1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount of Security sion or action action Derivative cisable and Underlying (Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Price of (Month/ quired (A) or Date Instr. 3 and 4) Deriv- Day/ (Instr. 8) Disposed of (Month/Day/ Secur- ative Year) Year) ity Security (Instr. 3, 4 (Instr. and 5) 5) Date Expira- Amount or Exer- tion Title Number of (A) (D) cisable Date Shares Stock Options (right to buy) $4.25 08/04/99 A (2) 5,000 08/01/01 08/04/04 Class A Common 5,000 Stock Stock Options (right to buy) $4.25 08/04/99 A (2) 5,000 08/01/02 08/04/04 Class A Common 5,000 Stock Stock Options (right to buy) $4.25 08/04/99 A (2) 5,000 08/01/03 08/04/04 Class A Common 5,000 Stock Stock Options (right to buy) $1.47 01/28/00 A (3) 3,750 01/28/01 01/28/05 Class A. Common 3,750 Stock Stock Options (right to buy) $1.47 01/28/00 A (3) 3,750 01/28/02 01/28/05 Class A. Common 3,750 Stock Stock Options (right to buy) $0.19 12/11/01 A (4) 5,000 12/01/03 12/11/06 Class A Common 5,000 Stock Stock Options (right to buy) $0.19 12/11/01 A (4) 5,000 12/01/04 12/11/06 Class A Common 5,000 Stock Stock Options (right to buy) $0.19 12/11/01 A (4) 5,000 12/01/05 12/11/06 Class A Common 5,000 Stock
8. Price 9. Number 10. Owner- 11. Na- of of Deriv- ship ture Deriv- ative Form of In- ative Secur- of De- direct Secur- ities rivative Bene- ity Bene- Secur- ficial ity; Own- Direct ership (D) or Indi- (Instr. 4) rect(I) (Instr. 4) 52,500(5) D
Explanation of Responses: (1) Ownership of these securities was previously reported on a Form 3, 4, or 5. (2) The reporting person was granted Stock Options to purchase 15,000 shares of the Company's Class A Common Stock under the NCS HealthCare, Inc. 1998 Performance Plan in reliance upon the exemption provided by Rule 16b-3. (3) The reporting person was granted Stock Options to purchase 7,500 shares of the Company's Class A Common Stock under the NCS HealthCare, Inc. 1998 Performance Plan in reliance upon the exemption provided by Rule 16b-3. (4) The reporting person was granted Stock Options to purchase 15,000 shares of the Company's Class A Common Stock under the NCS HealthCare, Inc. 2000 Performance Plan in reliance upon the exemption provided by Rule 16b-3. (5) The reporting person previously reported the grant of Stock Options on October 25, 2000 to purchase 35,000 shares of the Company's Class A Common Stock that expire on October 25, 2005. These options were granted under the NCS HealthCare, Inc. 1998 Performance Plan. ** Intentional misstatements or omissions of fact constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). /s/ Richard L. Osborne 08/09/2002 - ------------------------------------------------------ **Signature of Reporting Person Date 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 2 -----END PRIVACY-ENHANCED MESSAGE-----