5 1 p64622fe5.txt FORM 5 - JOSEPH KEALY 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 to Kealy Joseph P. INTERNATIONAL FIBERCOM, INC. (IFCI) Issuer (Check all applicable) --------------------------------------------------------------------------------------------- X Director 10% Owner (Last) (First) (Middle) 3. IRS Identification 4. Statement for ---- --- Number of Reporting Month/Year X Officer (give Other (specify 3410 East University, Suite 180 Person, if an entity ---- title --- below) ------------------------------------------- (voluntary) below) (Street) CHAIRMAN AND PRESIDENT ------------------------ --------------------------------------------------------- 5. If Amendment, 7. Individual or Joint/Group Date of Original Reporting (Month/Year) (check applicable line) X Form filed by One --- Reporting Person Form Filed by More than Phoenix Arizona 85034 --- 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 (Month/ (Instr. 8) the end of Direct Benefi- Day/ Issuer's Fiscal (D) or cial Year) Year (Instr. Indirect Owner- ---------------------------- 3 and 4) (I) ship Amount (A) or Price (Instr. (Instr. (D) 4) 4) ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 306,231 D ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ * 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. quired (A) or Date (Instr. 3 and 4) ative Deriv- Day/ 8) 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 ------------------------------------------------------------------------------------------------------------------------------------ Common Employee Stock Option $14.31 5/31/00 75,000 5/31/00 5/30/05 Stock 75,000 ------------------------------------------------------------------------------------------------------------------------------------ (Right to Buy) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------- 1. Title of Derivative 9. Number of 10. Ownership Form 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) ------------------------------------------------------------------------------------------------------- 75,000 D ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Explanation of Responses: **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). /s/ Joseph P. Kealy Feb. 14, 2001 ------------------------------- -------------- **Signature of Reporting Person Date Note: File three copies of this Form, one of which must be manually signed. Page 2 If space is insufficient, see Instruction 6 for procedure. SEC 2270 (3/91) 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.