3 1 0001.txt FORM 3 FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 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(f) of the Investment Company Act of 1940 (Print or Type Responses) ================================================================================ 1. Name and Address of Reporting Person Horner Derrick L. -------------------------------------------------------------------------------- (Last) (First) (Middle) c/o Source Media, Inc., 5400 LBJ Freeway, Suite 680 -------------------------------------------------------------------------------- (Street) Dallas TX 75240 -------------------------------------------------------------------------------- (City) (State) (Zip) ================================================================================ 2. Date of Event Requiring Statement (Month/Day/Year) 11/06/2000 ================================================================================ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ================================================================================ 4. Issuer Name and Ticker or Trading Symbol Source Media, Inc. (SRCM) ================================================================================ 5. Relationship of Reporting Person(s) to Issuer (Check all applicable) [ ] Director [ ] 10% Owner [ X ] Officer (give title below) [ ] Other (specify below) Vice President and General Counsel ================================================================================ 6. If Amendment, Date of Original (Month/Day/Year) ================================================================================ 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 BENEFICIALLY OWNED ================================================================================ ------------------------------- ---------------------------- ---------------------------- ---------------------------- 2. Amount of Securities 3. Ownership Form: 4. Nature of Indirect 1. Title of Security Beneficially Owned Direct (D) or Beneficial (Instr. 4) (Instr. 4) Indirect (I) (Instr. 5) Ownership (Instr. 5) ------------------------------- ---------------------------- ---------------------------- ---------------------------- ------------------------------- ---------------------------- ---------------------------- ---------------------------- ------------------------------- ---------------------------- ---------------------------- ---------------------------- ------------------------------- ---------------------------- ---------------------------- ---------------------------- ------------------------------- ---------------------------- ---------------------------- ---------------------------- ------------------------------- ---------------------------- ---------------------------- ---------------------------- ------------------------------- ---------------------------- ---------------------------- ----------------------------
* 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 5(b)(v) Form 3 (continued)
TABLE II - DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) ----------------- ------------------------ ------------------------------ ------------------ ---------------- ------------------- 5. Ownership Form of Derivative 6. Nature of 1. Title of 2. Date 3. Title and Amount of 4. Conversion or Security: Indirect Derivative Exercisable and Securities Underlying Exercise Price Direct (D) Beneficial Security Expiration Date Derivative Security of Derivation Indirect (I) Ownership (Instr. 4) (Month/Day/ Year) (Instr. 4) Security (Instr. 5) (Instr. 5) ----------------- ------------------------ ------------------------------ ------------------ ---------------- ------------------- Date Expiration Title Amount or Exercisable Date Number of Shares ----------------- ------------ ----------- -------------- --------------- ------------------ ---------------- ------------------- Employee Stock Option (Right to Buy) (1) 11/06/2010 Common Stock 150,000 $3.141 D ----------------- ------------ ----------- -------------- --------------- ------------------ ---------------- ------------------- ----------------- ------------ ----------- -------------- --------------- ------------------ ---------------- ------------------- ----------------- ------------ ----------- -------------- --------------- ------------------ ---------------- ------------------- ----------------- ------------ ----------- -------------- --------------- ------------------ ---------------- ------------------- ----------------- ------------ ----------- -------------- --------------- ------------------ ---------------- ------------------- ----------------- ------------ ----------- -------------- --------------- ------------------ ---------------- ------------------- ----------------- ------------ ----------- -------------- --------------- ------------------ ---------------- ------------------- ----------------- ------------ ----------- -------------- --------------- ------------------ ---------------- ------------------- ----------------- ------------------------ -------------- --------------- ------------------ ---------------- -------------------
Explanation of Responses: (1) The option vests in four equal annual installments beginning on November 6, 2001. By: /s/ Derrick L. Horner 11/13/2000 --------------------------------------------- ------------------ **Signature of Reporting Person Date Derrick L. Horner ** 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 procedures. 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 current valid OMB Number. Page 2