-----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, JcxfdzWbBaQJdTnph64XIaWkY00e8mwE24+jUaV0WYw+ehJRVxwUlohfz1ALuhyh AWJCOpdkxQfufLsqHWzAfw== 0000877937-98-000012.txt : 19980217 0000877937-98-000012.hdr.sgml : 19980217 ACCESSION NUMBER: 0000877937-98-000012 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 19971231 FILED AS OF DATE: 19980212 SROS: NONE SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: XEROGRAPHIC LASER IMAGES CORP /DE/ CENTRAL INDEX KEY: 0000877937 STANDARD INDUSTRIAL CLASSIFICATION: COMPUTER PERIPHERAL EQUIPMENT, NEC [3577] IRS NUMBER: 510319174 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: SEC FILE NUMBER: 001-11236 FILM NUMBER: 98534570 BUSINESS ADDRESS: STREET 1: 101 BILLERICA AVENUE STREET 2: 5 BILERICA PARK CITY: NORTH BILLERICA STATE: MA ZIP: 01801 BUSINESS PHONE: 5086705999 MAIL ADDRESS: STREET 1: 101 BILLERICA AVENUE STREET 2: 5 BILLERICA PARK CITY: NORTH BILLERICA STATE: MA ZIP: 01801 COMPANY DATA: COMPANY CONFORMED NAME: CARLEY ADAM L CENTRAL INDEX KEY: 0001035921 STANDARD INDUSTRIAL CLASSIFICATION: [] DIRECTOR STATE OF INCORPORATION: DE FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 101 BILLERICA AVE STREET 2: 5 BILLERICA PARK CITY: NORTH BILLERICA STATE: MA ZIP: 01862 BUSINESS PHONE: 5086705999 MAIL ADDRESS: STREET 1: 101 BILLERICA AVE STREET 2: 5BILLERICA PARK CITY: NORTH BILLERICA STATE: MA ZIP: 01862 5 1
UNITED STATES SECURITIES AND EXCHANGE COMMISSION FORM 5 Washington, D. C. 20549 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 here if no longer subject to Section 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 * |2 Issuer Name and Ticker/Trading Symbol|6 Relationship of Reporting | | | | Person(s) to Issuer | | Carley Adam L. |Xerographic Laser Images Corp. | (Check All Applicable) | | |---------------------------------------| ( X ) Director ( ) 10% Owner| | (Last) (First) (Middle)|3 IRS or Social |4 Statement for | ( ) Officer ( ) Other | | | Security Number | Month/Year | (Give Title below) (Specify below)| | 6 Hillside Road | of Reporting | | | | (Street 1) | Person | 12/31/97 | | | | (Voluntary) |---------------------|------------------------------------| | | |5 If Amendment, |7 Individual or Joint/Group Filing | | (Street 2) | ###-##-#### | Date of Original | (Check Applicable) | | | | (Month/Year) | Form filed by: | | Windham NH 03087 | | | (X) One Reporting Person | | (City) (State) (Zip) | | | ( ) More Than One Reporting Person| - ------------------------------------------------------------------------------------------------------------------------------------ Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned - ------------------------------------------------------------------------------------------------------------------------------------ |1 Title of Security |2 Trans- |3 Trans- |4 Securities Acquired |5 Amount of |6 Ownership|7 Nature of Indirect | | (Instruction 3) | action | action | (A) or Disposed of (D) | Securities | Form: | Beneficial Ownership | | | Date | Code | (Instructions 3, 4, 5) | Beneficially | Direct (D)| (Instruction 4) | | | (Month/ |(Instr 8)|------------------------| Owned at End | or | | | | Day/ | | Amount |(A)| Price | of Issuer's |Indirect(I)| | | | Year) | | |(D)| | Fiscal Year | (Instr 4) | | |--------------------------------|----------|---------|-----------|---|--------|--------------|-----------|------------------------| |Common Stock | | | | | | 104,917| D | | - ------------------------------------------------------------------------------------------------------------------------------------ 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). SEC 2270 (7-96)
FORM 5 (Continued) - ------------------------------------------------------------------------------------------------------------------------------------ Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (Puts, Calls, Warrants, Options, Convertible Securities) - ------------------------------------------------------------------------------------------------------------------------------------ | | | | | | | | | | | | |1 Title of |2 Con- |3 Trans-|4 Trans-|5 Number of |6 Date |7 Title and Amount|8 Price |9 Number|10 Own-|11 Nature| | Derivative | ver- | action | action | Derivative | Exercisable and | of Underlying | of |of Deri-|ership:| of | | Security | sion | Date | Code | Securities | Expiration Date | Securities | Deri- |vative |Direct |Indirect | | (Instr 3) | or | (Month/| (Instr | Acquired (A) or | (Month/Day/Year)|(Instructions 3,4)| vative |Secur- |(D) or |Ownership| | | Exer- | Day/ | 8) | Disposed of (D) |-----------------|------------------| Sec- |ties |Indi- |(Instr 4)| | | cise | Year) | |(Instrs 3, 4, 5) | Date | Expir- | |Amount | urity |Owned at|rect(I)| | | | Price | |--------|-----------------| Exer- | ation | Title |or Num- |(Instr |End of |(Instr | | | | | | | (A) | (D) | cisable| Date | |ber of | 5) |Year | 4) | | | | | | | | | | | |Shares | |(Instr4)| | | |------------|--------|--------|--------|--------|--------|--------|--------|---------|--------|--------|--------|-------|---------| | | | | | | | | | | | | 0| | | - ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: Adam L. Carley 2/11/98 _____________________________________ ___________ ** Signature of Reporting Person Date ** Intentional misstatement or ommissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). Note: Transmit one copy of this Form to EDGAR, using a typed signature. If space is insufficient, see Intruction 6 for procedure. SEC 2270 (7-96)
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