5 1 lo643522v2-form5.txt FORM 5
-------------------------------------------- ---------------------------------------- FORM 5 OMB Approval -------------------------------------------- ---------------------------------------- [_] Check this box if no longer subject to OMB Number: 3235-0287 Section 16. Form 4 or Form 5 Expires: obligations may continue. Estimated average burden See Instruction 1(b). hours per response...................0.5 [_] Form 3 Holdings Reported ---------------------------------------- [_] Form 4 Holdings Reported UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 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(f) of the Investment Company Act of 1940
------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or 6. Relationship of Reporting Person(s) to Issuer Trading Symbol (Check all applicable) Tyson Peter R. Lodgian, Inc. LOD ----------------------------- [X] Director [_] 10% Owner (Last) (First) (Middle) [_] Officer (give title below) [_] Other (specify below) ---------------------------------------------------- ------------------------- ----------------- 3. I.R.S. Identification 4. Statement for c/o Lodgian, Inc. Number of Reporting Month/Year 3445 Peachtree Road, N.E., Suite 700 Person, if an entity ----------------------------------------- (Voluntary) 12/01 (Street) Atlanta GA 30326 ---------------------------------------------------------------------------------------- ---------------------------------------- 5. If Amendment, Date of 7. Individual or Joint/Group Filing (City) (State) (Zip) Original (Month/Year) (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 Security 2. Transaction 3. Transaction 4. Securities Acquired 5. Amount of 6. Ownership Form: 7. Nature of (Instr. 3) Date Code (A) or Disposed of (D) Securities Direct (D) or Indirect (Month/Day/ (Instr. 8) (Instr. 3, 4 and 5) Beneficially Indirect (I) Beneficial /Year) Owned at End (Instr. 4) Ownership Of Issuer's (Instr. 4) Fiscal Year (Instr. 3 and 4) ------------------------------------------------------------------------------------------------------------------------------------ Code V Amount (A) or Price (D) ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, par value $0.01 per share 09/17/01 A 500 A $0.37 5,664 D ------------------------------------------------------------------------------------------------------------------------------------ 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 of Derivative 2. Conversion 3. Trans- 4. Trans- 5. Number of 6. Date Exercis- Security or Exercise action action Derivative able and Expiration (Instr. 3) Price of Date Code Securities Date Derivative (Month (Instr. Acquired (A) or (Month/Day/Year) Security /Day/ 8) Disposed of (D) Year) (Instr. 3, 4, and 5) ----------------------------------------------------------------------------------------------------------------------------------- (A) (D) Date Expiration Exercisable Date ----------------------------------------------------------------------------------------------------------------------------------- Option to Purchase Common Stock, par value $0.01 per share $0.69 6/21/01 A 5,000 6/21/01 6/20/01 ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------
(Table Continued)
1. Title of Derivative 7. Title and Amount of 8. Price of 9. Number of 10. Ownership 11. Nature of Security Underlying Securities Derivative Derivative Form of Indirect (Instr. 3) (Instr. 3 and 4) Security Securities Derivative Beneficial (Instr. 5) Beneficially Security: Ownership Owned at End Direct (D) (Instr. 4) Issuer's or Indirect Fiscal Year (I) (Instr. 4) (Instr. 4) ------------------------------------------------------------------------------------------------------------------------------------ Title Amount or No. of Shares ------------------------------------------------------------------------------------------------------------------------------------ Option to Purchase Common Stock, par value $0.01 per share Common Stock 5,000 70,000 D ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------
Explanation of Responses: None.
** Intentional misstatements or omissions /s/ Peter R. Tyson March 29, 2002 of facts constitute Federal Criminal ---------------------------------------- -------------------------------- Violations. See 18 U.S.C. and ** Signature of Reporting Person Date 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. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless form displays a currently valid OMB Number. Page 2 of 2 SEC 1473 (7-97)