5 1 p64622je5.txt FORM 5 - JOHN 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(s) to Kealy John F. 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 Officer (give Other (specify 520 South 52nd Street, Suite 201 Person, if an entity December 31, 2000 ---- title --- below) ------------------------------------------- (voluntary) ------------------- below) (Street) 5. If Amendment, ------------------------ Date of Original 7. Individual or Joint/Group Report- (Month/Year) ing (check applicable line) __ X__ Form Filed by One Reporting Person ______ Form Filed by More than One Tempe Arizona 85281 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 Issu- Direct Benefi- Day er's Fiscal Year (D) or cial Year ---------------------------- (Instr. 3 and 4) Indirect Owner- Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) ----------------------------------------------------------------------------------------------------------------------------------- Common Stock 10/13/00 A 30,000 A $6.00 D ----------------------------------------------------------------------------------------------------------------------------------- Common Stock 10/13/00 A 10,000 A $7.63 329,711 D ----------------------------------------------------------------------------------------------------------------------------------- 1,500 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 ------------------------------------------------------------------------------------------------------------------------------------ Option Common 10,000 (Right to Buy) $14.31 5/31/00 10,000 5/31/00 5/30/05 Stock ------------------------------------------------------------------------------------------------------------------------------------ Option Common 30,000 (Right to Buy) $6.00 10/13/00 M 30,000 5/20/99 5/17/04 Stock ------------------------------------------------------------------------------------------------------------------------------------ Option Common 10,000 (Right to Buy) $7.63 10/13/00 M 10,000 1/5/00 1/4/05 Stock ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------- 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) 10,000 D ------------------------------------------------------------------------------------------------------- Option -0- D (Right to Buy) ------------------------------------------------------------------------------------------------------- Option -0- D (Right to Buy) ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Explanation of Responses: **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. John F. Kealy Feb. 14, 2001 See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). --------------- ------------- **Signature of Date Reporting Person Note. File three copies of this Form, one of which must be manually signed. If space 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.