-----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, V6kzPPBVPnfkqKpQ55AQipYWJBp8ibe+R4HAajuzvubjwFAMG6imG/YZvz4cyKvF LWW9cUoX1Z88DKBdTY5fMw== 0000892569-98-002535.txt : 19980911 0000892569-98-002535.hdr.sgml : 19980911 ACCESSION NUMBER: 0000892569-98-002535 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 19980908 FILED AS OF DATE: 19980910 SROS: AMEX 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: 3 SEC ACT: SEC FILE NUMBER: 000-26980 FILM NUMBER: 98707242 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: [] OFFICER FILING VALUES: FORM TYPE: 3 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 3 1 FORM 3 FOR DOUGLAS M. PASQUALE 1 - -------- U.S. SECURITIES AND EXCHANGE COMMISSION --------------------------- FORM 3 WASHINGTON, DC 20549 OMB APPROVAL - -------- --------------------------- OMB Number: 3235-0104 Expires: September 30, 1998 Estimated average burden hours per response......0.5 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES --------------------------- Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(f) of the Investment Company Act of 1940
- ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Date of Event Requiring 4. Issuer Name and Ticker or 6. If Amendment, Date Statement Trading Symbol of Original Pasquale Douglas M. (Month/Day/Year) (Month/Day/Year) - ---------------------------------------- ARV Assisted Living, Inc. (SRS) (Last) (First) (Middle) 09/08/98 ---------------------------------- ----------------------- ---------------------------- 5. Relationship of Reporting 7. Individual or Joint/ 245 Fischer Avenue, Suite D-1 3. IRS or Social Security Person to Issuer Group Filing (Check - ---------------------------------------- Number of Reporting (Check all applicable) applicable line) (Street) Person (Voluntary) Director 10% Owner X Form filed by Costa Mesa CA 92626 ---------------------------- ----- ----- ----- One Reporting - ---------------------------------------- Person (City) (State) (Zip) X Officer Other ----- (give title ----- (specify Form filed by below) below) ----- More than One Reporting Person Presdent and Chief Operating Officer ------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ TABLE 1 -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Amount of Securities 3. Ownership Form: 4. Nature of Indirect (Instr. 4) Beneficially Owned Direct (D) or Beneficial (Instr. 4) Indirect (I) Ownership (Instr. 4) (Instr. 5) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 1,500 shares D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. Page 1 *If the form is filed by more than one Reporting Person, see Instruction 5(b)(v). SEC 1473 (7-96)
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FORM 3 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative Security 2. Date Exercisable 3. Title and Amount of 4. Conversion 5. Ownership 6. Nature of (Instr. 4) and Expiration Securities Underlying or Exercise Form of Indirect Date (Month/ Derivative Security Price of Derivative Beneficial Day/Year) (Instr. 4) Derivative Security: Ownership ------------------------------------------------- Security Direct (D) (Instr. 5) Date Expira- Title Amount or or Indirect Exercis- tion Date Number of (I) able Shares (Instr. 5) - ------------------------------------------------------------------------------------------------------------------------------------ Stock Option 06/01/00 06/01/08 Common Stock 37,500 $11.13 D - ------------------------------------------------------------------------------------------------------------------------------------ Stock Option 06/01/01 06/01/08 Common Stock 37,500 $11.13 D - ------------------------------------------------------------------------------------------------------------------------------------ Stock Option 06/01/02 06/01/08 Common Stock 37,500 $11.13 D - ------------------------------------------------------------------------------------------------------------------------------------ Stock Option 06/01/03 06/01/08 Common Stock 37,500 $11.13 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: /s/ Douglas M. Pasquale September 8, 1998 **Intentional misstatements or omissions of facts constitute Federal 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. 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 Page 2 SEC 1473 (7-96)
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