SEC Form 5
FORM 5 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
or Section 30(h) of the Investment Company Act of 1940
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
  
Form 3 Holdings Reported.
  
Form 4 Transactions Reported.
1. Name and Address of Reporting Person*
AMICO PETER

(Last) (First) (Middle)
870 B CENTRAL AVE

(Street)
HAMMONTON NJ 08037

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
AIRTRAX INC [ aitx ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
X Officer (give title below) Other (specify below)
Chairman, President
3. Statement for Issuer's Fiscal Year Ended (Month/Day/Year)
12/31/2003
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. 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
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned at end of Issuer's Fiscal Year (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Amount (A) or (D) Price
common stock 280,000 D
common stock 164,937 I Held by a third party under a loan agreement
common stock 1,630,623 I Held by Arcon Corp., a company wholly owned by Peter Amico
preferred stock 275,000 I Held by Arcon Corp., a company wholly owned by Peter Amico
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction Code (Instr. 8) 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
(A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Preferred Stock (1) (1) (1) Common Stock (1) 275,000(1) I The preferred stock is held by Arcon Corp., a company wholly owned by Peter Amico
1. Name and Address of Reporting Person*
AMICO PETER

(Last) (First) (Middle)
870 B CENTRAL AVE

(Street)
HAMMONTON NJ 08037

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
X Director X 10% Owner
X Officer (give title below) Other (specify below)
Chairman, President
1. Name and Address of Reporting Person*
ARCON CORP

(Last) (First) (Middle)
870 B CENTRAL AVE

(Street)
HAMMONTON NJ 08037

(City) (State) (Zip)

Relationship of Reporting Person(s) to Issuer
Director X 10% Owner
Officer (give title below) Other (specify below)
Explanation of Responses:
1. 1. The preferred stock has a stated value of $5.00 per share and an annual dividend equal to 5% of the stated value, payable quarterly. If funds are not legally available the dividend is payable in the form of common stock of the Company. Also, if funds are legally available, the holder can elect during any quarter to receive the dividend in the form of common stock. The price per share of common stock shall equal 30% of the lower of; the most recent price per share paid in a private offering or the closing price on the dividend record date.
/s/ Peter Amico by Daniel H. Luciano as Atty in Fact 02/17/2004
/s/ Arcon Corp. by Daniel H. Luciano as Atty in Fact 02/17/2004
** Signature of Reporting Person Date
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).
** 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 Number.