5 1 doc1.txt ------------------------------ OMB APPROVAL ------------------------------ OMB Number: 3235-0362 Expires: January 31, 2005 Estimated average burden hours per response.........1.0 ------------------------------ U.S. SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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 |_| Check box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). | | Form 3 Holdings Reported |_| Form 4 Transactions Reported ________________________________________________________________________________ 1. Name and Address of Reporting Person* Embry Russell T. ------------------------------------------------------------------------------- (Last) (First) (Middle) 246 Crossways Park West ------------------------------------------------------------------------------- (Street) Woodbury New York 11797 ------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol Intelli-Check, Inc. - IDN ________________________________________________________________________________ 3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year February 2003 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ page 1 FORM 5 (continued) 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) | | Director |_| 10% Owner |X| Officer (give title below) |_| Other (specify below) Title: Senior Vice President & Chief Technology Officer ________________________________________________________________________________ 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 I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================
5. 6. 4. Amount of Owner- Securities Acquired (A) or Securities ship 2A. 3. Disposed of (D) Beneficially Form: 7. 2. Deemed Transaction (Instr. 3, 4 and 5) Owned Direct Nature of Trans- Execution Code ------------------------------ at the End (D) or Indirect 1. action Date, if (Instr. 8) (A) of Issuer's Indirect Beneficial Title of Security Date any or Fiscal Year (I) Ownership (Instr. 3) (mm/dd/yy) (mm/dd/yy) Code V Amount (D) Price (Instr. 3 & 4) (Instr.4) (Instr.4) ---------------------------------------------------------------------------------------------------------------------------------- ===================================================================================================================================
* If the form is filed by more than one reporting person, see instruction 4(b)(v). 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 FORM 5 (continued) ================================================================================ Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
10. 9. Owner- Number ship 2. of of Conver- 5. 7. Deriv- Deriv- 11. sion Number of Title and Amount ative ative Nature or Derivative 6. of Underlying 8. Secur- Secur- of Exer- 3A. 4. Securities Date Securities Price ities ity: In- cise Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Bene- Direct direct Price 3. Execut- action or Disposed Expiration Date ---------------- Deriv- ficially (D) or Bene- 1. of Trans- ion Code of(D) (Month/Day/Year) Amount ative Owned In- ficial Title of Deriv- action Date if (Instr. (Instr. 3, ---------------- or Secur- at End direct Owner- Derivative ative Date any 8) 4 and 5) Date Expira- Number ity of Year (I) ship Security Secur- (mm/dd/ (mm/dd/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity yy) yy) (A) (D) cisable Date Title Shares 5) 4) 4) 4) ----------------------------------------------------------------------------------------------------------------------------------- Stock Option (right Common to buy) $3.82 10/31/02 A4 6,250 10/31/02 10/31/07 Stock 6,250 D ----------------------------------------------------------------------------------------------------------------------------------- Stock Option (right Common to buy) $3.82 10/31/02 A4 6,250 04/30/03 04/30/08 Stock 6,250 D ----------------------------------------------------------------------------------------------------------------------------------- Stock Option (right Common to buy) $7.50 07/15/99 A 10,000 07/15/00 07/15/05 Stock 10,000 D ----------------------------------------------------------------------------------------------------------------------------------- Stock Option (right Common to buy) $7.50 07/15/99 A 2,500 12/01/99 12/01/04 Stock 2,500 D ----------------------------------------------------------------------------------------------------------------------------------- Stock Option (right Common to buy) $7.50 07/15/99 A 2,500 07/03/00 07/03/05 Stock 2,500 D ----------------------------------------------------------------------------------------------------------------------------------- Stock Option (right Common to buy) $7.50 07/15/99 A 5,000 06/18/01 06/18/06 Stock 5,000 D ----------------------------------------------------------------------------------------------------------------------------------- Stock Option (right Common to buy) $11.625 12/13/99 A 10,000 12/13/99 12/13/04 Stock 10,000 D ----------------------------------------------------------------------------------------------------------------------------------- Stock Option (right Common to buy) $11.625 12/13/99 A 10,000 12/13/00 12/13/05 Stock 10,000 D ----------------------------------------------------------------------------------------------------------------------------------- Stock Option (right Common to buy) $8.75 07/11/00 A 12,500 07/11/00 07/11/05 Stock 12,500 D ----------------------------------------------------------------------------------------------------------------------------------- Stock Option (right Common to buy) $8.75 07/11/00 A 12,500 01/11/01 01/11/06 Stock 12,500 77,500 D =================================================================================================================================== Explanation of Responses:
/s/ Russell T. Embry February 14, 2003 --------------------------------------------- ----------------------- **Signature of Reporting Person Date ** 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 provided is insufficient, see Instruction 6 for procedure. 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 3