-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, WUu3usXfQN6jUK/14tzxKTBrzNunTWTe4hdiZGq9glN6mnXeDckT8ufW+PiaMN/Z N/mnDLzImhcgg+Gmx+1PNw== 0001047469-98-037715.txt : 19981021 0001047469-98-037715.hdr.sgml : 19981021 ACCESSION NUMBER: 0001047469-98-037715 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 19981009 FILED AS OF DATE: 19981020 SROS: NASD SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: FORWARD INDUSTRIES INC CENTRAL INDEX KEY: 0000038264 STANDARD INDUSTRIAL CLASSIFICATION: PLASTICS PRODUCTS, NEC [3089] IRS NUMBER: 131950672 STATE OF INCORPORATION: NY FISCAL YEAR END: 0930 FILING VALUES: FORM TYPE: 3 SEC ACT: SEC FILE NUMBER: 000-06669 FILM NUMBER: 98728061 BUSINESS ADDRESS: STREET 1: 400 POST AVENUE CITY: WESTBURY STATE: NY ZIP: 11590 BUSINESS PHONE: 5163380700 MAIL ADDRESS: STREET 1: 400 POST AVENUE CITY: WESTBURY STATE: NY ZIP: 11590 COMPANY DATA: COMPANY CONFORMED NAME: ELLIN ROBERT S CENTRAL INDEX KEY: 0001071292 STANDARD INDUSTRIAL CLASSIFICATION: [] OWNER FILING VALUES: FORM TYPE: 3 BUSINESS ADDRESS: STREET 1: 750 LEXINGTON AVE CITY: NEW YORK STATE: NY ZIP: 10022 BUSINESS PHONE: 2127505858 MAIL ADDRESS: STREET 1: 750 LEXINGTON AVE CITY: NEW YORK STATE: NY ZIP: 10022 3 1 FORM 3
- -------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION ----------------------------- FORM 3 WASHINGTON, D.C. 20549 OMB APPROVAL - -------- ----------------------------- INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES OMB Number: 3235-0104 Expires: September 30, 1998 Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Estimated average burden Section 17(a) of the Public Utility Holding Company Act of 1935 or hours per response .... 0.5 (Print or Type Responses) Section 30(f) of the Investment Company Act of 1940 ----------------------------- - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Date of Event Re- 4. Issuer Name AND Ticker or Trading Symbol quiring Statement Ellin Robert S. (1) (Month/Day/Year) Forward Industries, Inc. (FORD) - ------------------------------------------------- ----------------------------------------------------------- (Last) (First) (Middle) 10/9/98 5. Relationship of Reporting Person(s) 6. If Amendment, ----------------------- to Issuer (Check all applicable) Date of Original (Month/Day/Year) c/o Atlantis Equities, Inc. 750 Lexington Avenue ------------------- 3. IRS or Social Se- Director X 10% Owner curity Number of ---- ---- Reporting Person Officer (give Other (specify - ------------------------------------------------- (Voluntary) title below) below) 7. Individual or (Street) ---- ---- Joint/Group Filing (Check Applicable Line) - --------------------------- Form filed by One Reporting Person --- Form filed by More than One X Reporting Person New York, NY 10022 --- - ----------------------------------------------------------------------------------------------------------------------------------- (City) (State) (Zip) TABLE I -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED - ----------------------------------------------------------------------------------------------------------------------------------- 1. Title of Security 2. Amount of Securities 3. Ownership 4. Nature of Indirect Beneficial (Instr. 4) Beneficially Owned Form: Direct Ownership (Instr. 5) (Instr. 4) (D) or Indirect (I) (Instr. 5) - ----------------------------------------------------------------------------------------------------------------------------------- Common Stock, par value $.01 per share 17,500 D - ----------------------------------------------------------------------------------------------------------------------------------- Common Stock, par value $.01 per share 189,000 I By Atlantis Equities, Inc. - ----------------------------------------------------------------------------------------------------------------------------------- Common Stock, par value $.01 per share 37,500 I By Robert Ellin Family 1997 Trust - ----------------------------------------------------------------------------------------------------------------------------------- Common Stock, par value $.01 per share 8,000 I By Robert Ellin Profit Sharing Plan, as Trustee - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- Page 1 of 3 Pages
- ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative Security 2. Date Exer- 3. Title and Amount of Securities 4. Conver- 5. Owner- 6. Nature of Indirect (Instr. 4) cisable and Underlying Derivative Security sion or ship Beneficial Expiration (Instr. 4) Exercise Form of Ownership Date Price of Deriv- (Instr. 5) (Month/Day/ Deri- ative Year) vative Security: -------------------------------------------------- Security Direct Amount (D) or Date Expir- or Indirect Exer- ation Title Number (I) cisable Date of Shares (Instr. 5) - ------------------------------------------------------------------------------------------------------------------------------------ Warrants 12/9/98 3/15/99 Common Stock (2) 108,000 $4.00 D - ------------------------------------------------------------------------------------------------------------------------------------ Warrants 12/9/98 3/15/99 Common Stock (2) 15,000 $4.00 I By Atlantis Equities, Inc. - ------------------------------------------------------------------------------------------------------------------------------------ Warrants 12/9/98 3/15/99 Common Stock (2) 75,000 $4.00 I By Robert Ellin Profit Sharing Plan - ------------------------------------------------------------------------------------------------------------------------------------ Class B Warrants 3/25/96 12/11/98 Common Stock 91,500 $5.00 I By Atlantis Equities, Inc. - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: (1) Pursuant to Instruction 5(b)(v), this Form 3 is filed jointly by all of the /s/ Robert S. Ellin 10/19/98 undersigned (collectively, the "Reporting Persons"), who may be deemed to be members ------------------------------ -------- of a "group" pursuant to Section 13(d) of the Securities Exchange Act of 1934, as **Signature of Reporting Person Date amended. Robert S. Ellin ("Purchaser") has been designated to make the filing of this Form 3. (2) The Reporting Persons acquired these securities in the Company's private offering of securities consisting of units ("Units") consummated on December 4, 1997, each Unit comprised of (i) 30,000 shares of the Company's Common Stock, $.01 par value ("Common Stock"), (ii) one warrant ("Warrant") to purchase up to 30,000 shares of Common Stock at $4.00 per share and (iii) one unsecured convertible promissory note ("Note") in the principal amount of $10,000, bearing interest at a rate of 10% per annum (convertible at the sole option of the Company under certain circumstances, into 20,000 shares of Common Stock and one Warrant) maturing on December 4, 1998. The foregoing statement does not include principal amount of Notes held by Mr. Ellin, Atlantis Equities, Inc. and Robert Ellin Profit Sharing Plan in the amounts of $36,000, $5,000 and $25,000, respectively.
** 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 sufficient, 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 Number. SEC 1473 (9-96) Page 2 of 3 Pages FORM 3 (CONTINUED) Joint Filer Information Name: Robert S. Ellin Address: c/o Atlantis Equities, Inc. 750 Lexington Avenue New York, NY 10022 Name: Atlantis Equities, Inc. Address: c/o Atlantis Equities, Inc. 750 Lexington Avenue New York, NY 10022 Name: Robert Ellin Family 1997 Trust Address: c/o Marvin Ellin, Trustee 106 Central Park South New York, NY 10019 Name: Robert Ellin Profit Sharing Plan Address: c/o Atlantis Equities, Inc. 750 Lexington Avenue New York, NY 10022 Designated Filer: Robert S. Ellin Date of Event Requiring Statement: 10/09/98 Issuer and Ticker or Trading Symbol: Forward Industries, Inc. (FORD) Signature: /s/ Robert S. Ellin --------------------------- Robert S. Ellin ROBERT ELLIN FAMILY 1997 TRUST By: /s/ Marvin Ellin --------------------------- Marvin Ellin, Trustee ATLANTIS EQUITIES, INC. By: /s/ Robert S. Ellin --------------------------- Robert S. Ellin, President ROBERT ELLIN PROFIT SHARING PLAN By: /s/ Robert S. Ellin --------------------------- Robert S. Ellin, Trustee Page 3 of 3 Pages -----END PRIVACY-ENHANCED MESSAGE-----