3 1 p65933ke3.txt 3 ------------------------------ FORM 3 OMB APPROVAL ------------------------------ OMB Number: 3235-0104 Expires: December 31, 2001 Estimated average burden hours per response: 0.5 ------------------------------ U.S. SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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 (Print Or Type Responses) ________________________________________________________________________________ 1. Name and Address of Reporting Person* Roubin Gary S. -------------------------------------------------------------------------------- (Last) (First) (Middle) 910 5th Avenue, 16A -------------------------------------------------------------------------------- (Street) New York, New York 10021 -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Date of Event Requiring Statement (Month/Day/Year) 11/29/2001 ________________________________________________________________________________ 3. IRS or Social Security Number of Reporting Person (Voluntary) ________________________________________________________________________________ 4. Issuer name and Ticker or Trading Symbol Lipid Sciences, Inc. (LIPD) ________________________________________________________________________________ 5. Relationship of Reporting Person(s) to Issuer (Check all applicable) [X] Director [_] 10% Owner [_] Officer (give title below) [_] Other (specify below) ________________________________________________________________________________ 6. If Amendment, Date of Original (Month/Day/Year) ________________________________________________________________________________ 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 BENEFICIALLY OWNED ================================================================================
3. Ownership Form: 2. Amount of Securities Direct (D) or 1. Title of Security Beneficially owned Indirect (I) 4. Nature of Indirect Beneficial Ownership (Instr. 4) (Instr. 4) (Instr. 5) (Instr. 5) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Reminder: Report on a separate line for each class of securities owned directly or indirectly. * If the form is filed by more than one reporting person, see Instruction 5(b)(v). (Over) SEC 1473 (3-99) FORM 3 (continued) TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) ================================================================================
5. Owner- 3. Title and Amount of Securities ship Underlying Derivative Security Form of 2. Date Exercisable (Instr. 4) Derivative and Expiration Date --------------------------------- 4. Conver- Security: (Month/Day/Year) Amount sion or Direct 6. Nature of ---------------------- or Exercise (D) or Indirect Date Expira- Number Price of Indirect Beneficial 1. Title of Derivative Exer- tion of Derivative (I) Ownership Security (Instr. 4) cisable Date Title Shares Security (Instr. 5) (Instr. 5) ------------------------------------------------------------------------------------------------------------------------------------ Stock Option (right to buy) (1) 5/25/2010 Common Stock 155,902 $2.25 D ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: (1) - The option vested with respect to 1/3 of the shares on 5/25/2000, and it vests as to another 1/3 of the shares annually until it is fully vested on 5/25/2002. /s/ Gary S. Roubin 12/5/01 --------------------------------------------- ----------------------- **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 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