-----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, R1pUQlLt1/W9fUCKbFqWnT4Q9zomEYmTD1wAZFCM1jHWEzkXrN6o3oyOAxkPU60H CfJCzkPjUF2bqLxUEPB0Ew== 0000893220-03-000560.txt : 20030407 0000893220-03-000560.hdr.sgml : 20030407 20030407171919 ACCESSION NUMBER: 0000893220-03-000560 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030328 FILED AS OF DATE: 20030407 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: WL ROSS & CO LLC CENTRAL INDEX KEY: 0001202045 RELATIONSHIP: OWNER IRS NUMBER: 134106462 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 BUSINESS ADDRESS: STREET 1: 101 EAST 52ND STREET STREET 2: 19TH FLOOR CITY: NEW YORK STATE: NY ZIP: 10022 BUSINESS PHONE: 2128262042 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: PENN TREATY AMERICAN CORP CENTRAL INDEX KEY: 0000814181 STANDARD INDUSTRIAL CLASSIFICATION: ACCIDENT & HEALTH INSURANCE [6321] IRS NUMBER: 231664166 STATE OF INCORPORATION: PA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-14681 FILM NUMBER: 03641911 BUSINESS ADDRESS: STREET 1: 3440 LEHIGH ST CITY: ALLENTOWN STATE: PA ZIP: 18103 BUSINESS PHONE: 6109652222 MAIL ADDRESS: STREET 1: 3440 LEHIGH ST CITY: ALLENTOWN STATE: PA ZIP: 18103 3 1 w85249e3.htm PENN TREATY AMERICAN TRUST. e3
 

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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

FORM 3

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(h) of the Investment Company Act of 1940


1. Name and Address of Reporting
Person*
(Last, First, Middle)
2. Date of Event Requiring Statement
(Month/Day/Year)
3. I.R.S. Identification Number of Reporting
Person, if an entity
(voluntary)
  WL Ross & Co. LLC
  3/28/03
 
  101 East 52nd Street, 19th Floor

(Street)
4. Issuer Name and Ticker or Trading Symbol 5. Relationship of Reporting Person(s) to Issuer
(Check All Applicable)
    Penn Treaty American Corporation (PTA)
  o  Director
x  10% Owner
o  Officer (give title below)
o  Other (specify below)
  New York, NY 10022
(City)         (State)        (Zip)
6. If Amendment, Date of Original
(Month/Day/Year)
 
   
7. Individual or Joint/Group Filing
(Check Applicable Line)
                o  Form filed by One Reporting Person
x  Form filed by More than One Reporting Person

*   If the form is filed by more than one reporting person, see Instruction 5(b)(v).
 
Reminder:   Report on a separate line for each class of securities beneficially owned directly or indirectly.

 


 


Table I — Non-Derivative Securities Beneficially Owned

1. Title of Security
(Instr. 4)
2. Amount of Securities Beneficially Owned
(Instr. 4)
3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
4. Nature of Indirect Beneficial Ownership
(Instr. 5)

  Common Stock     10,698,286 (1)     I   By WLR Recovery Fund II, L.P. (2)

           

           

           

           

           

           

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Table II — Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)

1. Title of
Derivative
Security

(Instr. 4)
2. Date Exercisable and
Expiration Date

(Month/Day/Year)
3. Title and Amount of Securities
Underlying Derivative Security

(Instr. 4)
4. Conversion or
Exercise Price
of Derivative
Security
5. Ownership Form of
Derivative Security:
Direct (D) or Indirect (I)

(Instr. 5)
6. Nature of Indirect Beneficial Ownership
(Instr. 5)

      Date
Exer-
cisable
Expi-
ration
Date
 
Title
Amount
or
Number
of Shares
           

         

         

         

         

         

         

         

Explanation of Responses:

(1) The reporting persons beneficially own convertible notes which are convertible at any time into common stock of the issuer as follows: (i) $9,722,000 of notes at a conversion price of $1.75 per share, and (ii) $10,000,000 of notes at a conversion price of $1.75 per share.

(2) The shares are held directly by WLR Recovery Fund II, L.P. The general partner of WLR Recovery Fund II, L.P. is WLR Recovery Associates II LLC. Wilbur L. Ross, Jr. is the managing member, and W.L. Ross & Co. LLC is the advisor, of WLR Recovery Associates II LLC.

(3) Signing individually and on behalf of WLR Recovery Fund II, L.P., WLR Recovery Associates II LLC, and W.L. Ross & Co. LLC.

/s/ Wilbur L. Ross, Jr. (3)   4/7/03

**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 is insufficient, see Instruction 6 for procedure.
 

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