5 1 form5wsimon1201.txt FORM 5 - 12/01 ------------------------------ OMB APPROVAL ------------------------------ OMB Number 3235-0362 Expires: December 31, 2001 Estimated average burden hours per response ....... 1.0 ------------------------------ U.S. 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 Sec- tion 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). [_] Form 3 Holdings Reported [X] Form 4 Transactions Reported ________________________________________________________________________________ 1. Name and Address of Reporting Person* SIMON WILLIAM S. -------------------------------------------------------------------------------- (Last) (First) (Middle) 3003 WEST OLIVE AVENUE -------------------------------------------------------------------------------- (Street) BURBANK CALIFORNIA 91510-4590 -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol dick clark productions, inc. (dcpi) ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year June 30, 2001 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person to Issuer (Check all applicable) [ ] Director [ ] 10% Owner [X] Officer (give title below) [_] Other (specify below) VICE PRESIDENT OF FINANCE, TREASURER AND CHIEF FINANCIAL OFFICER ------------------------------------ ________________________________________________________________________________ 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. 6. 4. Amount of Owner- Securities Acquired (A) or Securities ship Disposed of (D) Beneficially Form: 7. (Instr. 3, 4 and 5) Owned at End Direct Nature of 2. 3. ----------------------------- of Issuer's (D) or Indirect 1. Transaction Transaction (A) Fiscal Year Indirect Beneficial Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership (Instr. 3) (mm/dd/yy) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4) ------------------------------------------------------------------------------------------------------------------------------------ None ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* 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) ================================================================================
9. 10. Number Owner- of ship 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. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) ------------------------------------------------------------------------------------------------------------------------------------ Options to Purchase Common Common Stock, par value (1) 9/1/00 A(1) 20,000 (1) 9/1/10 Stock 20,000 20,000 D $.01 per share ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: (1) Grant of options to purchase 20,000 shares of Common Stock, at an exercise price per share equal to $9.00, which shall vest and be exercisable as to 6,667 shares of Common Stock on September 1, 2001 and September 1, 2002 and as to 6,666 shares of Common Stock on September 1, 2003. ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). /s/ William S. Simon December 20, 2001 ------------------------------------------- ------------------ **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 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