5 1 lo648420-form5.txt ANNUAL STATEMENT OF CHANGES ------------------------- ------------------------------ FORM 5 UNITED STATES SECURITIES AND EXCHANGE COMMISSION OMB Approval ------------------------- WASHINGTON, D.C. 20549 ------------------------------ [ ] Check box if no OMB Number: 3235-0362 longer subject to Expires: PENDING 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 Weiner Richard H. [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 c/o Lodgian, Inc. (Voluntary) 12/01 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 Atlanta GA 30326 [ ] Form Filed by More than One --------------------------------------- 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) ------------------------------------------------------------------------------------------------------------------------------------ Amount (A) or (D) Price ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, par value 110,100 $0.01 per share ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ * If the form is filed by more than one reporting person, see Instruction 4(b)(v). Page 1 of 2 SEC 2270 (01-02)
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 of Indirect Deriv- Exercise Date Code Securities cisable Amount Deriv- Deriv- Deriv- Beneficial ative Price of (Month/ (Instr. Acquired (A) and Expir- of ative ative ative Ownership Secu- Deriv- Day/ 8) or Disposed ation 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) Year (Instr. 4) ---------------------------------------------------- (A) (D) Date Expir- Title Amount Exercis- ation or able Date Number of Shares ----------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ Option to Purchase Common Stock, par value Common $0.01/share $0.74 6/22/01 A 5,000 6/22/01 6/22/06 Stock 5,000 70,000 D ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: None. /s/ Richard H. Wiener May 10, 2002 ------------------------------------------ --------------------------- ** Signature of Reporting Person Date ** 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 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 2 of 2 SEC 2270 (01-02)