5 1 0001.txt 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: 3235-0287 longer subject to Expires: Section 16. Form 4 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Estimated average burden or Form 5 obligations hours per response.......0.5 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 Holdings Reported
------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Rerporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) Tyson Peter R. Lodgian, Inc. LOD [X] Director [ ] 10% Owner ------------------------------------------------------------------------------------------ [ ] Officer (give [ ] Other (specify (Last) (First) (Middle) 3. I.R.S. Identification 4. Statement for title below) Number of Reporting Month/Year below) Person, if an entity (Voluntary) 12/00 c/o Lodgian, Inc. ------------------------------------ 3445 Peachtree Road, N.E., Suite 700 ------------------------------------------ ------------------------------------------------------------- (Street) 5. If Amendment, 7. Individual or Joint/Group Filing Date of Original (Check Applicable Line) (Month/Year) [X] Form Filed by One Reporting Person [ ] Form Filed by More than One Atlanta GA 30326 Reporting 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) ------------------------------------------------------------------------------------------------------------------------------------ Code V Amount (A) or (D) Price ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, par value 04/01/00 A 616 A 3.75 3,364 D $0.01 per share ------------------------------------------------------------------------------------------------------------------- Common Stock, par value 07/01/00 A 616 A 2.38 3,364 D $0.01 per share ------------------------------------------------------------------------------------------------------------------- Common Stock, par value 10/01/00 A 616 A 2.88 3,364 D $0.01 per share ------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------- 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 4(b)(v). Page 1 of 2 SEC 1474 (7-97)
FORM 5 (continued) TABLE II -- DERIVATIVE SECURITIES 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 Form Indirect Deriv- Exercise Date Code Securities cisable Amount Deriv- Deriv- of Deriv- Beneficial ative Price of (Month/ (Instr. Acquired (A) and Expi- of ative ative ative Ownership Secu- Deriv- Day/ 8) or Disposed ration Under- Secu- Secu- Security: (Instr. 4) rity ative Year) of (D) Date lying rity rities Direct (Instr. Security (Instr. 3, (Month/ Securi- (Instr. Benefi- (D) or 3) 4, and 5) Day/ ties 5) cially Indirect Year) (Instr. Owned (I) 3 and 4) at End (Instr. of 4) Issuer's Fiscal Year (Instr. 4) -------------------------------------------- (A) (D) Date Expir- Title Amount Exercis- ation or able Date Number of Shares -------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ Option to Purchase Common Stock, par value $0.01 per Common share $3.81 10/20/00 A 5,000 10/20/00 10/20/10 Stock 5,000 65,000 D ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: None. ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. and 15 U.S.C. 78ff(a). Note: File three copies of this Form, one of which must be manually /s/ Peter R. Tyson February 14, 2001 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 number. Page 2 of 2 SEC 1473 (7-97)