-----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, VTViaudTUdeQlHfmRbQSg0cai4q+sldc+OU1Ugj3xTfgb3hFn2HM6joeB4bnnjt/ cYl77o+OT5NfrU9RvjVw+A== 0000892569-01-501054.txt : 20020410 0000892569-01-501054.hdr.sgml : 20020410 ACCESSION NUMBER: 0000892569-01-501054 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20011031 FILED AS OF DATE: 20011114 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: ARV ASSISTED LIVING INC CENTRAL INDEX KEY: 0000949322 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-NURSING & PERSONAL CARE FACILITIES [8050] IRS NUMBER: 330160968 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-26980 FILM NUMBER: 1788368 BUSINESS ADDRESS: STREET 1: 245 FISCHER AVE STREET 2: SUITE D-1 CITY: COSTA MESA STATE: CA ZIP: 92626 BUSINESS PHONE: 7147517400 MAIL ADDRESS: STREET 1: 245 FISCHER AVENUE STREET 2: SUITE D-1 CITY: COSTA MESA STATE: CA ZIP: 92626 COMPANY DATA: COMPANY CONFORMED NAME: PASQUALE DOUGLAS M CENTRAL INDEX KEY: 0001070021 STANDARD INDUSTRIAL CLASSIFICATION: [] DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: 245 FISHER AVE STE D-1 CITY: COSTA MESA STATE: CA ZIP: 92626 BUSINESS PHONE: 7147517400 MAIL ADDRESS: STREET 1: 245 FICHER AVE STE D-1 CITY: COSTA MESA STATE: CA ZIP: 92626 4 1 a77296e4.txt FORM 4 - ------ UNITED STATES SECURITIES AND EXCHANGE COMMISSION ------------------------------ FORM 4 WASHINGTON, D.C. 20549 OMB APPROVAL - ------ ------------------------------ STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OMB Number: 3235-0287 [ ] Check this box if no Expires: December 31, 2001 longer subject to Filed pursuant to Section 16(a) of the Securities Estimated average burden Section 16. Form 4 Exchange Act of 1934, Section 17(a) of the hours per response.........0.5 or Form 5 obligations Public Utility Holding Company Act of 1935 ------------------------------ may continue. See or Section 30(f) of the Investment Company Instruction 1(b). Act of 1940 (Print or Type Responses) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) PASQUALE DOUGLAS M. ARV ASSISTED LIVING, INC. (SRS) to Issuer (check all applicable) - -------------------------------------------- ---------------------------------------------- X Director 10% Owner (Last) (First) (Middle) 3. IRS Identification 4. Statement for ---- --- 245 FISCHER AVENUE, SUITE D-1 Number of Reporting Month/Year X Officer Other (specify - -------------------------------------------- Person, if an entity OCTOBER, 2001 ---- --- below) (Street) (Voluntary) ------------------- (give title below) COSTA MESA CALIFORNIA 92626 5. If Amendment, CHIEF EXECUTIVE OFFICER - -------------------------------------------- Date of Original ------------------------------------ (City) (State) (Zip) (Month/Year) 7. Individual or Joint/Group Filing ------------------- (Check Applicable Line) X Form filed by One ---- Reporting Person Form filed by More Than ---- One Reporting Person - ------------------------------------------------------------------------------------------------------------------------------------ TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature of (Instr. 3) action action or Disposed of (D) Securities Form: Indirect Date Code (Instr. 3, 4 and 5) Beneficially Direct Beneficial (Instr. 8) Owned at (D) or Ownership (Month/ End of Month Indirect (Instr. 4) Day/ --------------------------------------- (Instr. 3 and 4) (I) Year) Code V Amount (A) or Price (Instr. 4) (D) - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 10/24/01 P 2,000 A $1.23 99,500 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 10/25/00 P 200 A $1.35 99,500 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 10/29/01 P 2,800 A $1.23 99,500 D - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 10,500 I BY IRA - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. *If the form is filed by more than one reporting person, see Instruction 4(b)(v). (Over) SEC 1474 (3-99)
FORM 4 (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 Expiration Securities Deriv- Price of (Month/ (Instr. Acquired (A) Date (Instr. 3 and 4) ative Deriv- Day/ 8) or Disposed (Month/Day/ Secur- ative Year) of (D) (Instr. Year) ity Security 3, 4, and 5) (Instr. 5) ----------------------------------- Date Expira- Amount or -------------------------- Exer- tion Title Number of Code V (A) (D) cisable Date Shares - ------------------------------------------------------------------------------------------------------------------------------------ EMPLOYEE STOCK OPTION COMMON (RIGHT TO BUY) D(1) STOCK 150,000 - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ 9. Number of 10. Ownership 11. Nature of Derivative Form of Indirect Securities Derivative Beneficial Beneficially Security: Ownership Owned at End Direct (D) (Instr. 4) of Month or Indirect (I) (Instr. 4) (Instr. 4) - -------------------------------------------------------------------------- 900,000 D - -------------------------------------------------------------------------- - -------------------------------------------------------------------------- - -------------------------------------------------------------------------- - -------------------------------------------------------------------------- - -------------------------------------------------------------------------- - -------------------------------------------------------------------------- Explanation of Responses: (1) OPTION GRANTED ON JUNE 1, 1998 FOR 35,936 SHARES AT A STRIKE PRICE OF $11.13 WAS SURRENDERED VOLUNTARILY TO THE COMPANY. OPTION GRANTED ON JUNE 1, 1998 FOR 114,064 SHARES AT A STRIKE PRICE OF $11.13 WAS SURRENDERED VOLUNTARILY TO THE COMPANY. **Intentional misstatements or omissions of facts constitute Federal /s/ DOUGLAS M. PASQUALE NOVEMBER 12, 2001 Criminal Violations. 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. Douglas M. Pasquale 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.
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