3 1 lo-ellis_3.txt FORM 3 ------------------------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION ------------------------------ FORM 3 WASHINGTON, DC 20549 OMB APPROVAL ------------------------- INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES ------------------------------ OMB Number: 3235-0104 FILED PURSUANT TO SECTION 16(a) OF THE SECURITIES EXCHANGE ACT OF 1934, Expires: January 31, 2005 SECTION 17(a) OF THE PUBLIC UTILITY HOLDING COMPANY ACT OF 1935 OR Estimated average burden SECTION 30(h) OF THE INVESTMENT COMPANY ACT OF 1940 hours per response.......0.5 ------------------------------
(Print or Type Responses) ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Date of Event Requiring 4. Issuer Name AND Ticker or Trading Symbol Statement (Month/Day/Year) 11/25/02 Lodgian, Inc. (LDGIV) Ellis Daniel E. ------------------------------------------------------------------------------------ ------------------------------------ 3. I.R.S. Identification 5. Relationship of Reporting 6. If Amendment, Date of (Last) (First) (Middle) Number of Reporting Person(s) to Issuer Original Person, if an entity (Check all applicable) (Month/Day/Year) (voluntary) c/o Lodgian, Inc. [ ] Director 3445 Peachtree Road, N.E., Suite 700 [X] Officer ---------------------------- ------------------------------------ (give title below) 7. Individual or Joint/Group (Street) [ ] 10% Owner Filing [ ] Other (Check Applicable Line) Atlanta Georgia 30326 (specify below) [X] Form filed by One ------------------------------------ Reporting Person (City) (State) (Zip) Senior Vice President [ ] Form filed by More ------------------------- than One Reporting Person ------------------------------------------------------------------------------------------------------------------------------------ TABLE I -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Amount of Securities 3. Ownership Form: Direct (D) 4. Nature of Indirect (Instr. 4) Beneficially Owned or Indirect (I) (Instr. 5) Beneficial Ownership (Instr. 4) (Instr. 5) ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 10 (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 5(b)(v). PERSONS WHO 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.
FORM 3 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of 2. Date Exer- 3. Title and Amount of 4. Conversion or 5. Ownership 6. Nature of Derivative cisable and Securities Underlying Exercise Price Form of Indirect Security Expiration Derivative Security of Derivative Derivative Beneficial (Instr. 4) Date (Instr. 4) Security Securities: Ownership (Month/Day/Year) Direct (D) or (Instr. 5) Indirect (I) (Instr. 5) ------------------------------------------------------------------------------------------------------------------------------------ Date Expira- Title Amount or Exer- tion Number of cisable Date Shares ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: /s/ DANIEL E. ELLIS December 4, 2002 ----------------------------------- -------------------- ** 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 is insufficient, see Instruction 6 for procedure. PERSONS WHO 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.