4 1 a68513e4.txt FORM 4 1 ---------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION ------------------------------- FORM 4 WASHINGTON, DC 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 Instruction 1(b). Investment Company 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) to Issuer (Check all applicable) Pasquale Douglas M. ARV ASSISTED LIVING, INC. (SRS) X Director 10% Owner --------------------------------------------- ---------------------------------------------- --- --- (Last) (First) (Middle) 3. IRS Identification 4. Statement for X Officer Other Number of Reporting Month/Year --- (give title --- (Specify title 245 Fischer Avenue, Suite D-1 Person, if an entity December, 2000 below) below) --------------------------------------------- (Voluntary) ------------------- President and (Street) 5. If Amendment, Chief Executive Officer ----------------------- Date of -------------------------------- Costa Mesa CA 92626 Original 7. Individual or Joint/Group Filing --------------------------------------------- (Month/Year) (Check Applicable Line) (City) (State) (Zip) X Form filed by one ------------------ --- Reporting Person Form filed by more than --- one Reporting Person ------------------------------------------------------------------------------------------------------------------------------------ TABLE 1 -- 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 (D) Beneficial (Instr. 8) Owned at or Ownership (Month/ ------------- ------------------------- End of Month Indirect (I) (Instr. 4) Day/ (A) or (Instr. 3 and 4) (Instr. 4) Year) Code V Amount (D) Price ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 12/04/00 P 2,700 A $.4375 87,000 D ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 12/05/00 P 2,300 A $.4375 87,000 D ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 12/28/00 P 5,000 A $.50 87,000 D ------------------------------------------------------------------------------------------------------------------------------------ 10,500 I By IRA ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over) *If the Form is filed by more than one Reporting Person, see Instruction 4(b)(v). SEC 1474 (3-99)
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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. Transaction 5. Number of 6. Date Exer- 7. Title and 8. Price of Security sion or action Code Derivative cisable and Amount of Derivative (Instr. 3) Exercise Date (Instr. 8) Securities Expiration Underlying Security Price of (Month/ Acquired (A) Date Securities (Instr. 5) Derivative Day/ or Disposed of (Month/Day/ (Instr. Security Year) (D) (Instr. 3, Year) 3 and 4) 4, and 5) ---------------- ----------------- Date Expira- Amount or -------------- ---------------- Exer- tion Number of Code V (A) (D) cisable Date Title Shares ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------- 1. Title of Derivative 9. Number of 10. Ownership 11. Nature of Security Derivative Form of Indirect (Instr. 3) Securities Derivative Beneficial Beneficially Security: Ownership Owned at End Direct (D) (Instr. 4) of Month or Indirect (I) (Instr. 4) (Instr. 4) ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Explanation of Responses: **Intentional misstatements or omissions of facts constitute Federal Criminal /s/ DOUGLAS M. PASQUALE January 8, 2001 Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). -------------------------- --------------- **Signature of Date Reporting Person Douglas M. Pasquale 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. 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.