5 1 0001.txt FORM 5 U.S. SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 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(f) of the Investment Company Act of 1940 -------------------------- OMB APPROVAL -------------------------- OMB Number: 3235-0362 Expires: December 31, 2001 Estimated average burder hours per response ...1.0 -------------------------- [_] 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 [X] Form 4 Transactions Reported -------------------------------------------------------------------------------- 1. Name and Address of Reporting Person* Casuarina Cayman Holdings Ltd. -------------------------------------------------------------------------------- (Last) (First) (Middle) 207 Grandview Drive -------------------------------------------------------------------------------- (Street) Fort Mitchell KY 41017 -------------------------------------------------------------------------------- (City) (State) (Zip) -------------------------------------------------------------------------------- 2. Issuer Name and Ticker or Trading Symbol Lodgian, Inc./LOD -------------------------------------------------------------------------------- 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) -------------------------------------------------------------------------------- 4. Statement for Month/Year 7/00 -------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Year) -------------------------------------------------------------------------------- 6. Relationship of Reporting Person to Issuer (Check all applicable) [_] Director [X] 10% Owner [_] Officer (give title below) [_] Other (specify below) -------------------------------------------------------------------------------- 7. Individual or Joint/Group Filing (Check applicable line) [_] Form filed by one Reporting Person [X] 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 Disposed of (D) Beneficially Form: 7. (Instr. 3, 4 and 5) Owned at End Direct Nature of 2. 3. ----------------------------- of Issuer's (D) or Indirect 1. Transaction Transaction (A) Fiscal Year Indirect Beneficial Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership (Instr. 3) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4) (Month/ Day/ Year) ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, par value 5/25/00 P 1,100,000 A $2.00 4,191,800 (1) (1) $0.01 per share ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* 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 informa- tion contained in this form are not required to respond unless the form displays a currently valid OMB control number. (Over) SEC 2270 (3-99) Page 1 of 3 FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
9. 10. Number Owner- of ship 2. Deriv- of Conver- 5. 7. ative Deriv- 11. sion Number of Title and Amount Secur- ative Nature or Derivative 6. of Underlying 8. ities Secur- of Exer- Securities Date Securities Price Bene- ity: In- cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ None. ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: (1) Casuarina Cayman Holdings Ltd. ("Casuarina") directly owns 1,593,700 shares of Lodgian, Inc. per share (the "Shares"). Because William J. Yung may be deemed to control Casuarina, William J. Yung and Casuarina may be deemed to have beneficial ownership and voting and dispositive control of all such Shares held directly by Casuarina. In addition, the 1994 William J. Yung Family Trust (the "1994 Trust"), The 1998 William J. Yung and Martha A. Yung Family Trust (the "1998 Trust"), Edgecliff Management, LLC ("Management"), Edgecliff Holdings, LLC ("Holdings"), Joseph Yung and William J. Yung, may pursuant to Rule 13d-5 of the Securities Exchange Act of 1934 (the "Securities Act"), be deemed to be the beneficial owner of the 1,593,700 Shares owned directly by Casuarina. Holdings directly owns 2,598,100 Shares. William J. Yung as the sole managing member of Management, which is the sole managing member of Holdings, may be deemed to control Holdings and, therefore, William J. Yung and Holdings may be deemed to have beneficial ownership and voting and dispositive control of all such Shares held of record by Holdings. In addition, Casuarina, the 1994 Trust, the 1998 Trust, Management, Joseph Yung and William J. Yung, may, pursuant to Rule 13d-5 of the Securities Act, be deemed to be the beneficial owner of the 2,598,100 Shares owned directly by Holdings. CASUARINA CAYMAN HOLDINGS LTD. /s/William J. Yung July 24, 2000 --------------------------------------------- ----------------------- **Signature of Reporting Person Date Name: William J. Yung Title: President ** 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 informa tion contained in this form are not required to respond unless the form displays a currently valid OMB control number. Page 2 of 3 SEC 1474 (9-96) Joint Filer Information ----------------------- Designated Filer: Casuarina Cayman Holdings Ltd. Issuer and Ticker Symbol: Lodgian, Inc./LOD Statement of Month/Year: 7/00
Listing of Names and Addresses Signatures of Other of Other Reporting Persons Reporting Persons Date ----------------------------------------------------------------------------------------------------------- Edgecliff Holdings, LLC EDGECLIFF HOLDINGS, LLC 207 Grandview Drive Fort Mitchell, KY 41017 By: /s/ William J. Yung 7/24/00 ------------------------------ ------- Name: William J. Yung Title: President Edgecliff Management, LLC EDGECLIFF MANAGEMENT, LLC 207 Grandview Drive Fort Mitchell, KY 41017 By: /s/ William J. Yung 7/24/00 ------------------------------ ------- Name: William J. Yung Title: President 1994 William J. Yung Family Trust 1994 WILLIAM J. YUNG FAMILY TRUST 207 Grandview Drive Fort Mitchell, KY 41017 By: The Fifth Third Bank, as Trustee By: /s/ Robert Erickson 7/24/00 ------------------------------ ------- Name: Robert Erickson Title: Trust Officer Joseph Yung /s/ Joseph Yung 7/24/00 207 Grandview Drive ------------------------------ ------- Fort Mitchell, KY 41017 Joseph Yung William J. Yung William J. Yung /s/ William J. Yung 7/24/00 1200 Cypress Street ------------------------------ ------- Cincinnati, OH 45206 William J. Yung The 1998 William J. Yung 1998 WILLIAM J. YUNG AND and Martha A. Yung Family Trust MARTHA A. YUNG FAMILY TRUST 207 Grandview Drive Fort Mitchell, KY 41017 By: The Fifth Third Bank, as Trustee By: /s/ Robert Erickson 7/24/00 ------------------------------ ------- Name: Robert Erickson Title: Trust Officer
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