-----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, S3tt9xwwaGZGmczaWhthtTJwSbolInlnPKPNwQqs8gC+E0oIa3q1m6/ZSltFueAE kGvpFeORVKRiOKg8ZJeMzQ== 0000914121-00-000184.txt : 20000216 0000914121-00-000184.hdr.sgml : 20000216 ACCESSION NUMBER: 0000914121-00-000184 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 19991231 FILED AS OF DATE: 20000215 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: LODGIAN INC CENTRAL INDEX KEY: 0001066138 STANDARD INDUSTRIAL CLASSIFICATION: HOTELS & MOTELS [7011] IRS NUMBER: 522093696 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: SEC FILE NUMBER: 001-14537 FILM NUMBER: 546087 BUSINESS ADDRESS: STREET 1: 3445 PEACHTREE ROAD N E SUITE 700 CITY: ATLANTA STATE: CA ZIP: 30326 BUSINESS PHONE: 4043649400 MAIL ADDRESS: STREET 1: 3445 PEACHTREE ROAD N E SUITE 700 CITY: ATLANTA STATE: CA ZIP: 30326 COMPANY DATA: COMPANY CONFORMED NAME: LEVEN MICHAEL A CENTRAL INDEX KEY: 0001040619 STANDARD INDUSTRIAL CLASSIFICATION: HOTELS & MOTELS [7011] DIRECTOR STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: C/O US FRANCHISE SYSTEMS INC STREET 2: 13 CORPORATE SQUARE CITY: ATLANTA STATE: GA ZIP: 30329 BUSINESS PHONE: 4043214045 MAIL ADDRESS: STREET 1: STARWOOD HOTELS RESORTS WORLDWIDE INC STREET 2: 44 SOUTH BROADWAY CITY: AWHITE PLAINS STATE: NY ZIP: 10601 FORMER COMPANY: FORMER CONFORMED NAME: LAVEN MICHAEL A DATE OF NAME CHANGE: 19970609 5 1 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP - ------------------------- ------------------------------ FORM 5 UNITED STATES SECURITIES AND EXCHANGE COMMISSION OMB Approval - ------------------------- Washington, D.C. 20549 ------------------------------ [ ] Check this box if no OMB Number: 3235-0362 longer subject to Expires: December 31, 2001 Section 16. Form 4 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Estimated average burden or Form 5 obligations hours per response.......1.0 may continue. See ------------------------------ Instruction 1(b). Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, [ ] Form 3 Holdings Section 17(a) of the Public Utility Holding Company Act of 1935 or Reported Section 30(f) of the Investment Company Act of 1940 [ ] Form 4 Transactions Reported
- --------------------------------------------------- ------------------------------------------------------ ------------------------- 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) Lodgian, Inc. LOD Leven Michael A. [X] Director [ ] 10% Owner - ---------------------------------------------------------------------------------------- [ ] Officer (give [ ] Other (specify (Last) (First) (Middle) 3. IRS or Social 4. Statement for title below) Security Number of Month/Year below) Reporting Person c/o Lodgian, Inc. (Voluntary) 12/99 3445 Peachtree Road, N.E., Suite 700 ------------------------------------ - ------------------------------------------ --------------------------------------------------------------- (Street) 5. If Amendment, 7. Individual or Joint/Group Reporting Date of Original (check applicable line) (Month/Year) [X] Form Filed by One Reporting Person [ ] Form Filed by More than One Reporting Atlanta GA 30326 Person - ------------------------------------------------------------------------------------------------------------------------------------ (City) (State) (Zip) TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Transaction 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature of (Instr. 3) action Code (Instr. or Disposed of (D) Securities Form: Indirect Date 8) (Instr. 3, 4 and 5) Beneficially Direct (D) Beneficial (Month/ Owned at End or Indirect Ownership Day/ of Issuer's (I) (Instr. 4) Year) Fiscal Year (Instr. 4) (Instr. 3 and 4) - ------------------------------------------------------------------------------------------------------------------------------------ Amount (A) or (D) Price - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, par value 1/1/99(1) A 1,231 A 4.875 10,724 D $.01 per share - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, par value 4/1/99(1) A 1,231 A 4.4375 10,724 D $.01 per share - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, par value 7/1/99(1) A 1,231 A 6.5625 10,724 D $.01 per share - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, par value 10/1/99(1) A 1,231 A 3.75 10,724 D $.01 per share - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, par value 12/21/98 3(2) 5,700 10,724 I (2) $.01 per share - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ * If the form is filed by more than one reporting person, see Instruction 4(b)(v). Page 1 of 2 SEC 2270 (3-99)
FORM 5 (continued) TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED (e.g., puts, calls, warrants, options, convertible securities) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date 7. Title 8. Price 9. Number 10. Owner- 11. Nature of of sion or action action Derivative Exer- and of of ship Indirect Deri- Exercise Date Code Securities cisable Amount Deri- Deri- Form Beneficial vative Price of (Instr. Acquired (A) and Expi- of vative vative of Deri- Ownership Secu- Deri- (Month/ 8) or Disposed ration Under- Secu- Secu- vative (Instr. 4) rity vative Day/ of (D) Date Lying rity rities Security: (Instr. Security Year) (Instr. 3, (Month/ Securi- (Instr. Benefi- Direct 3) 4, and 5) Day/ ties 5) cially (D) or Year) (Instr. Owned Indirect 3 and 4) at End (I) of (Instr. Year 4) (Instr. 4) --------------------------------------------------- (A) (D) Date Expir- Title Amount Exerci- ation or sable Date Number of Shares --------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------------ Option to $6.50 6/25/99 A 5,000 6/25/99 6/25/09 Common 5,000 30,000 D Purchase Stock Common Stock, par value $0.01/share - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: (1) Date represents the date of grant by the issuer. The certificates for these shares were received December 17, 1999. (2) Represents indirect ownership of 5,700 shares of the Issuer's Common Stock owned by the Reporting Person's spouse which should have been reported on the Reporting Person's Initial Statement of Beneficial Ownership of Securities on Form 3, which was filed on December 22, 1998, the date on which the Reporting Person's filing obligations began. ** 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 /s/ Michael A. Leven February 10, 2000 signed. If space is insufficient, see Instruction 6 for ------------------------------------ -------------------- procedure. ** Signature of Reporting Person Date 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 control number. Page 2 of 2 SEC 2270 (3-99)
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