-----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, Wa1xYiEeI3ZzQfNO/DbBQsFAg9JPIk36Llk1kD9Qu2NwMJWgKeAdMHs7lRIuc0EM c19WMhzrJBiJQI/pb5T/8A== 0000914760-03-000011.txt : 20030129 0000914760-03-000011.hdr.sgml : 20030129 20030129164345 ACCESSION NUMBER: 0000914760-03-000011 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030128 FILED AS OF DATE: 20030129 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: ARLINGTON HOSPITALITY INC CENTRAL INDEX KEY: 0000778423 STANDARD INDUSTRIAL CLASSIFICATION: HOTELS & MOTELS [7011] IRS NUMBER: 363312434 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-15291 FILM NUMBER: 03530237 BUSINESS ADDRESS: STREET 1: 2355 SOUTH ARLINGTON HEIGHTS ROAD STREET 2: SUITE 400 CITY: ARLINGTON HEIGHTS STATE: IL ZIP: 60005 BUSINESS PHONE: 8472285400 MAIL ADDRESS: STREET 1: 2355 SOUTH ARLINGTON HEIGHTS ROAD STREET 2: SUITE 400 CITY: ARLINGTON HEIGHTS STATE: IL ZIP: 60005 FORMER COMPANY: FORMER CONFORMED NAME: AMERICA POP INC DATE OF NAME CHANGE: 19871111 FORMER COMPANY: FORMER CONFORMED NAME: AMERIHOST PROPERTIES INC DATE OF NAME CHANGE: 19920703 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: ROMANO THOMAS J CENTRAL INDEX KEY: 0001216420 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: ARLINGTON HOSPITALITY INC STREET 2: 2355 S ARLINGTON HEIGHTS RD CITY: ARLINGTON HEGHTS STATE: IL ZIP: 60005 BUSINESS PHONE: 8472285400 MAIL ADDRESS: STREET 1: 2355 S ARLINGTON HEIGHTS RD STE 400 CITY: ARLIGTON HEIGHTS STATE: IL ZIP: 60005 4 1 a32381_form4romano.htm THOMAS J. ROMANO - JANUARY 28, 2003 - FORM 4 Form 4

FORM 4

 

UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549

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(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).

 

  

 

(Print or Type Responses)

1. Name and Address of Reporting Person*          




 DAYAN SALOMON J.

2. Issuer Name and Ticker or Trading Symbol

 Arlington Hospitality, Inc. "HOST"

6. Relationship of Reporting Person(s) to Issuer
                  (Check all applicable)

   X

Director

 

10% Owner

   

Officer (give
title below)

 

Other (specify
below)

 

(Last)                    (First)                (Middle)


 2837 Sheridan Place

3. I.R.S. Identification
   Number of Reporting
   Person, if an entity
   (Voluntary)

 

4. Statement for
    Month/Day/Year

 January 28, 2003



7. Individual or Joint/Group Filing (Check Applicable Line)

5. If Amendment,
    Date of Original
    (Month/Day/Year)

 

   X

Form filed by One Reporting Person

(Street)

 Evanston IL 60201

   

Form filed by More than One Reporting Person

(City)                      (State)                  (Zip)

Table I ¾  Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

1. Title of Security
    (Instr. 3)

2. Trans-
    action
    Date



  (Month/
    Day/
   Year)

2A.
Deemed
Execution
Date, if
any

  (Month/
    Day/
   Year)

3. Trans-
    action
    Code
    (Instr.8)

4. Securities Acquired (A)
    or Disposed of (D)
    (Instr. 3, 4 and 5)

5. Amount of
    Securities
    Beneficially
    Owned
    Following
    Reported
    Transaction(s)

    (Instr. 3 and 4)

6. Owner-
    ship
    Form:
    Direct
    (D) or
    Indirect
    (I)

  (Instr. 4)

7. Nature of
    Indirect
    Beneficial
    Owner-
    ship



   (Instr. 4)

Code

V

Amount

(A)
or
(D)

Price

 Common Stock

 1/28/03

 

 P

 

 5,000

 A

 $3.35

 228,812

 I

 (1)

 Common Stock

 

 

 

 

 

 

 

 4,000

 I

 (2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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).

 

                                                                                                                 

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 control number.

     

(Over)
SEC 1474 (9-02)

 

 

FORM 4 (continued)

Table II ¾  Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)

1. Title of Derivative
    Security
    (Instr. 3)

2. Conver-
    sion or
    Exercise
    Price of
    Deri-
    vative
   Security

3. Trans-
    action
    Date

(Month/
 Day/
Year)

3A.
Deemed
Execution
Date, if
any

  (Month/
   Day/
  Year)

4. Trans-
    action
    Code
    (Instr.8)

5. Number of Deriv-
    ative Securities Ac-
    quired (A) or Dis-
    posed of (D)
    (Instr. 3, 4 and 5)

6. Date Exer-
    cisable and
    Expiration
    Date
    (Month/Day/
    Year)

7. Title and Amount of
    Underlying Securities
    (Instr. 3 and 4)

8. Price
    of
    Deriv-
    ative
    Secur-
    ity
    (Instr.
    5)

9. Number
   of deriv-
   ative
   Secur-
   ities
   Bene-
   ficially
   Owned
   Follow-
   ing
   Reported
   Trans-
   action(s)
   (Instr. 4)

10. Owner-
     ship
     Form of
     Deri-
     vative
     Security:
     Direct
     (D) or
     Indirect
     (I)
     (Instr. 4)

11. Nature
     of
     Indirect
     Benefi-
     cial
     Owner-
     ship
     (Instr. 4)

Code

V

(A)

(D)

Date
Exer-
cisable

Expira-
tion
Date

Title

Amount or
Number of
Shares

 Options issued 08/30/96

 

 

 

 

 

 

 

 

 

 

 

 

 1,000

 D

 

 Options issued 08/14/97

 

 

 

 

 

 

 

 

 

 

 

 

 1,000

 D

 

 Options issued 08/06/98

 

 

 

 

 

 

 

 

 

 

 

 

 1,000

 D

 

 Options issued 05/27/99

 

 

 

 

 

 

 

 

 

 

 

 

 1,000

 D

 

 Convertible Partnership Interests (3)

 

 

 

 

 

 

 

 

 

 

 

 

 84,050

 I

 (1)

 Options issued 03/30/00

 

 

 

 

 

 

 

 

 

 

 

 

 2,500

 D

 

 Options issued 06/01/00

 

 

 

 

 

 

 

 

 

 

 

 

 1,000

 D

 

 Options issued 10/13/00

 

 

 

 

 

 

 

 

 

 

 

 

 62,500

 I

 (1)

 Options issued 05/25/01

 

 

 

 

 

 

 

 

 

 

 

 

 1,000

 D

 

 Options issued 08/16/02

 

 

 

 

 

 

 

 

 

 

 

 

 1,000

 D

 

Options issued 09/12/02 (4)

             

(5)

       

2,500

D

 

Explanation of Responses:

 (1) Table I - Item 7 and Table II - Item 11 - Represents securities owned by Salomon J. Dayan UTD 11/08/78.

(2) Table I - Item 7 - Represents securities owned by the children of Salomon J. Dayan.

(3) Table II - Item 1 - Represents equity interests in partnerships in which Arlington Hospitality, Inc. is the general partner. Dr. Dayan's interests are convertible into shares of Arlington Hospitality, Inc. common stock at a conversion rate of $8.00 per share.

(4) Table II - Item 1 - Represents Options to purchase shares of common stock issued as director compensation. These options are subject to shareholder approval if required by law or NASD.

(5) Table II - Item 6 - Options vest only if Arlington Hospitality, Inc. achieves certain financial performance objectives for 2002.

 

 

 /s/ Thomas J. Romano

          

 January 28, 2003

**

Intentional misstatements or omissions of facts constitute Federal Criminal Violations.

**Signature of Reporting Person

          

Date

 

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.

 

     

 

 

 

 

     

 

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required to respond unless the form displays a currently valid OMB Number.

 

     

 

 

 

     

 

 

 

     

Page 2

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