5 1 p64622he5.txt FORM 5 - JERRY KLEVEN 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) KLEVEN JERRY A. INTERNATIONAL FIBERCOM, INC. (IFCI) to Issuer (Check all applicable) --------------------------------------------------------------------------------------------- X Director 10% Owner (Last) (First) (Middle) 3. IRS or Identification 4. Statement for ---- --- Number of Reporting Month/Year Officer (give Other (Specify 3410 EAST UNIVERSITY, SUITE 180 Person, if an entity December 31, 2000 ---- title --- below) ------------------------------------------- (Voluntary) ------------------- below) (Street) 5. If Amendment, ----------------------------------- Date of Original 7. Individual or Joint/Group (Month/Year) Reporting (check applicable line) PHOENIX ARIZONA 85034 X Form Filed by One Reporting --- Person 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) the end of Issu- Direct Benefi- (Month/ er's 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 12/18/00 M 20,000 A $1.47 D ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 12/18/00 F 4,900 D $6.00 156,296 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. 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 ------------------------------------------------------------------------------------------------------------------------------------ Option Common (Right to Buy) $7.625 1/05/00 30,000 1/25/00 1/04/05 Stock 30,000 ------------------------------------------------------------------------------------------------------------------------------------ Option Common (Right to Buy) $12.9375 4/14/00 50,000 4/14/00 4/13/05 Stock 50,000 ------------------------------------------------------------------------------------------------------------------------------------ Option Common (Right to Buy) $14.31 5/31/00 10,000 5/31/00 5/30/05 Stock 10,000 ------------------------------------------------------------------------------------------------------------------------------------ Option Common (Right to Buy) $1.47 12/18/00 M 20,000 4/22/97 4/21/02 Stock 20,000 ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------- 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) ------------------------------------------------------------------------------------------------------- Option (Right to Buy) -0- D ------------------------------------------------------------------------------------------------------- Option (Right to Buy) -0- D ------------------------------------------------------------------------------------------------------- Option (Right to Buy) -0- D ------------------------------------------------------------------------------------------------------- Option (Right to Buy) -0- D ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Explanation of Responses: Feb 14, **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ Jerry A. Kleven 2001 See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------------- ------- **Signature of Reporting Person Date 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 IN THIS FORM ARE NOT REQUIRED TO RESPOND UNLESS THE FORM DISPLAYS A CURRENTLY VALID OMB NUMBER.