-----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, IyZN91gkgBBLx8/tc3++ZQWlRo0y9DKvyDq3XJUnWBZKkzxYmcSHvJUPqWPgO/Dh svrr5vtZ24gRphAPUcSEkA== 0000931731-03-000254.txt : 20030725 0000931731-03-000254.hdr.sgml : 20030725 20030724181928 ACCESSION NUMBER: 0000931731-03-000254 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20020731 FILED AS OF DATE: 20030725 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: GILLESPIE THOMAS J CENTRAL INDEX KEY: 0000904931 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-24801 FILM NUMBER: 03801805 BUSINESS ADDRESS: STREET 1: 191 SUN VALLEY RD CITY: KETCHUM STATE: ID ZIP: 83340 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: AQUA VIE BEVERAGE CORP CENTRAL INDEX KEY: 0001068104 STANDARD INDUSTRIAL CLASSIFICATION: BEVERAGES [2080] IRS NUMBER: 820506425 STATE OF INCORPORATION: WA FISCAL YEAR END: 0731 BUSINESS ADDRESS: STREET 1: 333 SOUTH MAIN STREET STREET 2: PO BOX 6759 CITY: KETCHUM STATE: ID ZIP: 83340 BUSINESS PHONE: 2086227792 MAIL ADDRESS: STREET 1: PO BOX 6759 STREET 2: 333 SOUTH MAIN STREET CITY: KETCHUM STATE: ID ZIP: 83340 FORMER COMPANY: FORMER CONFORMED NAME: BARHILL ACQUISITION CORP DATE OF NAME CHANGE: 19980812 5 1 form5-tg073102_ex.xml X0101 5 2002-07-31 0 0 0001068104 AQUA VIE BEVERAGE CORP AQVB 0000904931 GILLESPIE THOMAS J 1 1 0 0 Chief Executive Officer Common Stock - See Attached Notes 2000-08-31 2000-08-31 5 P 0 69192 .001 A 69192 D Thomas J. Gillespie 2003-07-18 EX-99.1 3 ex99no1.txt TABLES WITH FOOTNOTES
THOMAS J. GILLESPIE - FORM 5 REPEATING CHART SUBMITTED IN XML FORMAT IN ORDER TO INCLUDE FOOTNOTES Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned 5. 6. 4. Amount of Owner- Securities Acquired (A) or Securities ship Disposed of (D) Beneficially Form: 7. 3. (Instr. 3, 4 and 5) Owned at End Direct Nature of 2. Transaction of Issuer's (D) or Indirect 1. Transaction Code (A) Fiscal Year Indirect Beneficial Title of Security Date (Instr. 8) Amount or Price (Instr. 3 (I) Ownership (Instr. 3) (mm/dd/yy) Code V (D) and 4) (Instr.4) (Instr. 4) =========================================================================================================================== Common Stock No Par Value 08/31/2000(1) p 69,192 A 0.001 69,192(2) D - --------------------------------------------------------------------------------------------------------------------------- Common Stock No Par Value - --------------------------------------------------------------------------------------------------------------------------- Common Stock No Par Value - --------------------------------------------------------------------------------------------------------------------------- - --------------------------------------------------------------------------------------------------------------------------- - --------------------------------------------------------------------------------------------------------------------------- - --------------------------------------------------------------------------------------------------------------------------- - ---------------------------------------------------------------------------------------------------------------------------
Page 2 of 3 Pages FORM 4 (continued) ================================================================================ Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
9. 10. Number Owner- of ship 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. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- 4. or Disposed Expiration Date Deriv- Owned (D) or Bene- 1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date action (Instr. 3, or Secur- of direct Owner Derivative ative (Month /Code 4 and 5) Date Expira- Number ity Year (I) -ship Security Secur- Day/ (Instr. 8 Exer- tion of (Instr.(Instr. (Instr. (Instr. (Instr. 3) ity Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4) =================================================================================================================================== Preferred Series G N/A 05/31/02 P 10,000 05/31/03 Common Note 3 10,000 D - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- ===================================================================================================================================
Explanation of Responses: (1) All original issuances previous to August 31, 2000: 15,000 8/31/2000 (reissued post-split 09/02) (2) Beneficial ownership = common plus preferred - See Note 3 for Preferred. (3) Preferred Series G has basic conversion ratre of 700 shares of common for every share of preferred/enhanced voting rights 4 times conversion rate. The conversion rate is adjusted upward in the event issuance of shares in a transaction less than $0.40/share, and in the event of market performance Series J&K issuance would affect the beneficial ownership; but the calculation of value for the adjustments has not yet been determined by the board. /s/ Thomas J. Gillespie 07/18/03 - ----------------------------------- ----------- **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 provided is insufficient, see Instruction 6 for procedure. Page 3 of 3 Pages
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