5 1 p64622ce5.txt FORM 5 - JAMES JENSEN 1 --------------------------- OMB APPROVAL --------------------------- ------ OMB Number: 3235-0362 FORM 5 Expires: December 31, 2001 ------ Estimated average burden hours per response .... 1.0 --------------------------- / / Check box if no UNITED STATES SECURITIES AND EXCHANGE COMMISSION longer subject to WASHINGTON, D.C. 20549 Section 16. Form 4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP obligations may continue. See Filed pursuant to Section 16(a) of the Securities Instruction 1(b) Exchange Act of 1934, / / Form 3 Holdings Section 17(a) of the Public Utility Reported Holding Company Act of 1935 or Section 30(f) of / / Form 4 the Investment Company Act Transactions of 1940 Reported ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) Jensen James C. INTERNATIONAL FIBERCOM, INC. (IFCI) to Issuer (Check all applicable) -------------------------------------------------------------------------------------------- x Director 10% Owner (Last) (First) (Middle) 3. IRS Identification 4. Statement for ---- --- Number of Reporting Month/Year Officer (give Other (specify 101 Wild Oak Court Person, if an entity December 31, 2000 ---- title --- below) ------------------------------------------- (voluntary) ------------------- below) (Street) 5. If Amendment, 7. Individual or Joint/Group Reporting Date of Original (check applicable line) (Month/Year) x Form Filed by One Reporting Person Danville California 94506 -- ---- Form Filed by More than One reporting Person ------------------------------------------- ------------------------------------------------------------------------------------- (City) (State) (Zip) TABLE 1 -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature (Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In- Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct (Instr. 8) End of Issuer's Direct Benefi- (Month/ Fiscal Year (D) or cial Day/ ---------------------------- (Instr. 3 and 4) Indirect Owner- Year) Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, no par value 10/13/00 M 150,000 A $6.00 202,293 D ------------------------------------------------------------------------------------------------------------------------------------ Common Stock, no par value 1,950 I by Children ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ * If the form is filed by more than one reporting person, see instruction 4(b)(v). (Over) SEC 2270 (7/96)
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FORM 5 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED (e.g., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price Security sion or action action Derivative cisable and of Underlying of (Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv- Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative Deriv- Day/ Disposed of (D) (Month/Day/ Secur- ative Year) (Instr. 3, 4, Year) ity Security and 5) (Instr. 5) ----------------------------------- Date Expira- Amount or --------------- Exer- tion Title Number of (A) (D) cisable Date Shares ------------------------------------------------------------------------------------------------------------------------------------ Options Common (Right to Buy) $7.625 1/05/00 A 10,000 1/05/00 1/04/05 Stock 10,000 ------------------------------------------------------------------------------------------------------------------------------------ Options Common (Right to Buy) $14.31 5/31/00 A 10,000 5/31/00 5/31/05 Stock 10,000 ------------------------------------------------------------------------------------------------------------------------------------ Options Common (Right to Buy) $6.00 10/13/00 M 150,000 5/20/99 5/19/04 Stock 150,000 ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------- 1. Title of Derivative 9. Number of 10. Ownership 11. Nature of Security Derivative of Derivative Indirect (Instr. 3) Securities Security: Beneficial Beneficially Direct (D) Ownership Owned at End or Indirect (I) (Instr. 4) of month (Instr. 4) (Instr. 4) ------------------------------------------------------------------------------------------------------- 10,000 D ------------------------------------------------------------------------------------------------------- 10,000 D ------------------------------------------------------------------------------------------------------- -0- D ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Explanation of Responses: /s/ C. James Jensen Feb. 14, 2001 ------------------------------- ------------- **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. 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.