5 1 form5rfriedman022003.txt FEBRUARY 2003 ------------------------------ 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* Friedman Robert N. -------------------------------------------------------------------------------- (Last) (First) (Middle) c/o Loehmann's Holdings, Inc. 2500 Halsey Street -------------------------------------------------------------------------------- (Street) New York NY 10461 -------------------------------------------------------------------------------- (City) (State) (Zip) -------------------------------------------------------------------------------- 2. Issuer Name and Ticker or Trading Symbol Loehmann's Holdings, Inc. ("LHMS") -------------------------------------------------------------------------------- 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) -------------------------------------------------------------------------------- 4. Statement for Month/Year February 2003 -------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Year) -------------------------------------------------------------------------------- 6. Relationship of Reporting Person to Issuer (Check all applicable) [X] Director [ ] 10% Owner [X] Officer (give title below) [ ] Other (specify below) Chief Executive 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. 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 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) ================================================================================
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) ------------------------------------------------------------------------------------------------------------------------------------ Option to Purchase Common Common Stock $7.75(3) 5/10/02 A 150,000(3) (1) 5/9/12 Stock 150,000(3) 150,000(3) D ------------------------------------------------------------------------------------------------------------------------------------ Option to Purchase Common Common Stock $6.125(3) 3/25/02 A 200,000(3) (2) 3/24/12 Stock 200,000(3) 200,000(3) D ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: (1) In three equal installments of 50,000 on each of June 30, 2004, June 30 2005 and June 30, 2006 (2) As of the date of this filing, immediately as to 150,000 and 50,000 on October 10, 2003 (3) Reflects a 2 for 1 stock split on October 15, 2002 /s/ Robert Friedman 4/28/2003 ------------------------------------------- ----------------- **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