-----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, Oijrt11enP/0qnGbT0xJBMHWnsKARAJJq9n8e6YJu04ribKfXpGMWta53I85Olpx aV5MGtGum7mgI5iKrhRm+g== 0001019056-01-000123.txt : 20010224 0001019056-01-000123.hdr.sgml : 20010224 ACCESSION NUMBER: 0001019056-01-000123 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20001231 FILED AS OF DATE: 20010216 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: LATIN AMERICAN CASINOS INC CENTRAL INDEX KEY: 0000880242 STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-AUTO DEALERS & GASOLINE STATIONS [5500] IRS NUMBER: 650159115 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: SEC FILE NUMBER: 000-19709 FILM NUMBER: 1548516 BUSINESS ADDRESS: STREET 1: 2000 NE 164TH ST CITY: NORTH MIAMI BEACH STATE: FL ZIP: 33162 BUSINESS PHONE: 3057561000 MAIL ADDRESS: STREET 1: 2000 NE 164TH ST CITY: N MIAMI BEACH STATE: FL ZIP: 33162 COMPANY DATA: COMPANY CONFORMED NAME: FELDER JEFFREY A CENTRAL INDEX KEY: 0001135096 STANDARD INDUSTRIAL CLASSIFICATION: [] OFFICER FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 18421 NW 18TH ST CITY: POMBROKE PINES STATE: FL ZIP: 33029 BUSINESS PHONE: 3059459300 MAIL ADDRESS: STREET 1: 18421 NW 18TH ST CITY: POMBROKE PINES STATE: FL ZIP: 33029 5 1 0001.txt FORM 5
- --------------------------------------- FORM 5 - --------------------------------------- -------------------------------- OMB APPROVAL -------------------------------- [ ] CHECK THIS BOX IF NO LONGER OMB Number: 3235-0362 SUBJECT TO SECTION 16. FORM 4 OR FORM Expires: October 31, 2001 5 OBLIGATIONS MAY CONTINUE. SEE Estimated average burden INSTRUCTION 1(b). hours per response ........ 1.0 [ ] FORM 3 HOLDINGS REPORTED [X] FORM 4 TRANSACTIONS REPORTED U.S. SECURITIES AND EXCHANGE COMMISSION (Print or Type Responses) 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 - ------------------------------------------------------------------------------------------------------------------------------------ 1.Name and Address of Reporting Person*(1) 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person to Issuer Felder, Jeffrey Latin American Casinos, Inc., "LACI" (Check all applicable) - -------------------------------------------------------------------------------------------- (Last) (First) (Middle) 3. IRS or Social 4. Statement for Month/Year [ ] Director [ ] 10% Owner Security Number [X] Officer [ ] Other of Reporting 2000 (give title (specify 2000 NE 164th Street Person below) below) - --------------------------------------- (Voluntary) (Street) President ---------------------------- - ------------------------------------------------------------------------------------------------------------------------------------ North Miami Beach, Florida 33162 5. If Amendment, 7. Individual or Joint/Group Filing - --------------------------------------- Date of Original (Check Applicable Line) (City) (State) (Zip) (Month/Year) [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 - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Ownership Form: 7. Nature of (Instr.3) action action Code or Disposed of (D) Securities Direct (D) or Indirect Date (Instr. 8) (Instr. 3,4 and 5) Beneficially Indirect (I) Beneficial Owned at End of (Instr. 4) Ownership (Month/ Issuer's (Instr. 4) Day/Year)------------------------------------------------- Fiscal Year Code V Amount (A) or (D) Price (Instr. 3 and 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ (OVER) *If the form is filed by more than one reporting person, SEE Instruction 4(b)(v). SEC 2270(3/99) 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 CONTROL NUMBER. Page 1 of 2
FORM 5 (continued) Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (E.G., puts, calls, warrants, options, convertible securities) - --------------------------------------------------------------------------------- 1. Title of 2. Conversion 3. Transaction 4. Transaction 5. Number of Derivative or Exercise Date Code Derivative Security Price of (Month/Day/Year) (Instr. 8) Securities (Instr. 3) Derivative Acquired (A) Security or Disposed of (D) (Instr. 3, 4 and 5) ---------------- (A) (D) - --------------------------------------------------------------------------------- Option $1.75 10/3/2000 A4 10,000 - --------------------------------------------------------------------------------- - --------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------- 6. Date 7. Title and Amount 8. Price of 9. Number of 10. Ownership 11. Nature of Exercisable of Underlying Derivative Derivative Form of Indirect and Expiration Securities Security Securities Derivative Beneficial Date (Instr. 3 and 4) (Instr. 5) Beneficially Security: Ownership (Month/Day/Year) Owned at Direct (D) or (Instr. 4) End of Indirect (I) Year (Instr. 4) (Instr. 4) ------------------------------------------ Amount Date Expir- or Exer- ation Number cisable Date Title of Shares - ----------------------------------------------------------------------------------------------------------- Common (See explana- 10/3/2000 10/2/2010 Stock 25,000 tion below) 35,000 D - ----------------------------------------------------------------------------------------------------------- - -----------------------------------------------------------------------------------------------------------
Explanation of Responses: Options issued by Latin American Casinos, Inc. to the Reporting Person in consideration for employment arrangement. ** 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. By: Jeffrey Felder /s/ JEFFREY FELDER February 13, 2001 -------------------------------- ----------------- **Signature of Reporting Person Date 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 of 2 SEC 2270 (7-97) -----END PRIVACY-ENHANCED MESSAGE-----