-----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, UBSHWBV1I2HJIcDyCH5t5JBjHAKKz+aasz57SHLu2kyYrGeI9/mgvctZJ33MuvJc lwpVox2OdF6fLTbK2tom3Q== 0000910680-03-000134.txt : 20030214 0000910680-03-000134.hdr.sgml : 20030214 20030213184433 ACCESSION NUMBER: 0000910680-03-000134 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021231 FILED AS OF DATE: 20030214 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: SIEGEL HOWARD M CENTRAL INDEX KEY: 0001005726 RELATIONSHIP: OWNER FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 3265 LAWSON BLVD CITY: OCEANSIDE STATE: NY ZIP: 11572 BUSINESS PHONE: 5165365850 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: AMERICAN MEDICAL ALERT CORP CENTRAL INDEX KEY: 0000700721 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MISCELLANEOUS BUSINESS SERVICES [7380] IRS NUMBER: 112571221 STATE OF INCORPORATION: NY FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 001-08635 FILM NUMBER: 03561933 BUSINESS ADDRESS: STREET 1: 3265 LAWSON BLVD CITY: OCEANSIDE STATE: NY ZIP: 11572 BUSINESS PHONE: 5165365850 MAIL ADDRESS: STREET 1: 3265 LAWSON BLVD CITY: OCEANSIDE STATE: NY ZIP: 11572 5 1 form5jhsiegel122002.txt HOWARD M. SIEGEL (12/2002) ------------------------------ OMB APPROVAL ------------------------------ OMB Number 3235-0362 Expires: January 31, 2005 Estimated average burden hours per response ....... 1.0 ------------------------------ UNITED STATES 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 [ ] 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 [ ] Form 4 Transactions Reported - -------------------------------------------------------------------------------- 1. Name and Address of Reporting Person* Siegel Howard M. - -------------------------------------------------------------------------------- (Last) (First) (Middle) c/o American Medical Alert Corp. 3265 Lawson Boulevard - -------------------------------------------------------------------------------- (Street) Oceanside New York 11572 - -------------------------------------------------------------------------------- (City) (State) (Zip) - -------------------------------------------------------------------------------- 2. Issuer Name and Ticker or Trading Symbol American Medical Alert Corp. ("AMAC") - -------------------------------------------------------------------------------- 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) - -------------------------------------------------------------------------------- 4. Statement for Month/Year December, 2002 - -------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Year) - -------------------------------------------------------------------------------- 6. Relationship of Reporting Person to Issuer (Check all applicable) [X] Director [X] 10% Owner [X] Officer (give title below) [ ] Other (specify below) Chairman, President and CEO - -------------------------------------------------------------------------------- 7. Individual or Joint/Group Filing (Check applicable line) [X] Form filed by one Reporting Person [ ] Form filed by more than one Reporting Person - -------------------------------------------------------------------------------- ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================
5. Amount of 6. Owner- 2A. 4. Securities Acquired (A) or Securities ship 7. Nature 2. Trans- Deemed 3. Trans- Disposed of (D) Beneficially Form: of action Execution action (Instr. 3, 4 and 5) Owned at End Direct Indirect Date Date, if Code -------------------------- of Issuer's (D) or Benefi- 1. Title (Month/ any Month/ (Instr.8) (A) Fiscal Indirect cial of Security Day/ Day/ or Year (Instr. (I) Ownership (Instr. 3) Year) Year) Amount (D) Price 3 and 4) (Instr.4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, par value $.01 per share 990,719 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
*If the form is filed by more than one reporting person see instruction 4(b)(v). (Over) SEC 2270 (3-99) FORM 5 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) ================================================================================
10. 9. Owner- Number ship of Form 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. 3A. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- Deemed 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Execution Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date Date, if action (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ any Code 4 and 5) Date Expira- Number ity Year (I) ship Security Secur- Day/ (Month/Day (Instr. ----------- Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $2.52 Immed. 01/28/08 Stock 8,500 8,500 D - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $2.53 08/13/02 A 7,942 Immed. 08/13/07 Stock 7,942 7,942 D - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $4.004 03/13/02 A 20,000 Immed. 03/13/07 Stock 20,000 20,000 D - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $3.157 12/31/01 A 7,788 Immed. 12/31/06 Stock 7,788 7,788 D - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $1.90 Immed. 10/29/06 Stock 10,000 10,000 D - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $3.025 Immed. 7/24/06 Stock 8,750 8,750 D - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $2.75 Immed. 12/31/05 Stock 160,000 160,000 D - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $2.475 Immed. 7/03/05 Stock 5,750 5,750 D - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $2.20 Immed. 1/04/05 Stock 15,750 15,750 D - ------------------------------------------------------------------------------------------------------------------------------------ TABLE II -- CONTINUED ================================================================================ 10. 9. Owner- Number ship of Form 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. 3A. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- Deemed 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Execution Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date Date, if action (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ any Code 4 and 5) Date Expira- Number ity Year (I) ship Security Secur- Day/ (Month/Day (Instr. ----------- Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $2.6125 Immed. 9/16/04 Stock 11,442 11,442 D - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $4.1938 Immed. 1/04/04 Stock 24,000 24,000 D - ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock $3.1350 Immed. 8/31/03 Stock 9,183 9,183 D ====================================================================================================================================
Explanation of Responses: /s/ Howard M. Siegel 2/13/03 - ------------------------------------------- ----------------- **Signature of Reporting Person Date * 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 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 number. Page 2 -----END PRIVACY-ENHANCED MESSAGE-----