-----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, SXKkqa7VmK0f8GeDItDLQGVNBf0SSx19VV7lx2Rk0nLFrtEBA9amflxSuPb6spMW AqqD1TairZVxN7KAX19vpg== 0001095811-01-502360.txt : 20010517 0001095811-01-502360.hdr.sgml : 20010517 ACCESSION NUMBER: 0001095811-01-502360 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20001231 FILED AS OF DATE: 20010516 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: SEC FILE NUMBER: 000-26980 FILM NUMBER: 1641171 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: KHOURY ABDO H CENTRAL INDEX KEY: 0001073166 STANDARD INDUSTRIAL CLASSIFICATION: [] OFFICER FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: C/O ARV ASSISTED LIVING INC STREET 2: 245 FISCHER AVE SUITE D-1 CITY: COSTA MESA STATE: CA ZIP: 92626 BUSINESS PHONE: 7147517400 MAIL ADDRESS: STREET 1: C/O ARV ASSISTED LIVING INC STREET 2: 245 FISCHER AVE SUITE D-1 CITY: COSTA MESA STATE: CA ZIP: 92626 4 1 a72824e4.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) Khoury Abdo H. ARV ASSISTED LIVING, INC. (SRS) 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 Chief (Street) 5. If Amendment, Financial 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 22,300 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 1,700 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 - ------------------------------------------------------------------------------------------------------------------------------------ EMPLOYEE STOCK OPTION Common (RIGHT TO BUY) 12/14/00 A (1) 12/13/10 Stock 125,000 0.5625 - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------- 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) - ------------------------------------------------------------------------------------------------------- EMPLOYEE STOCK OPTION (RIGHT TO BUY) 382,500 D - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- Explanation of Responses: (1) THE OPTION VESTS IN THREE EQUAL INSTALLMENTS OVER A THREE YEAR PERIOD. THE FIRST INSTALLMENT WILL VEST ON THE FIRST OF THE QUARTER IMMEDIATELY FOLLOWING THE COMPANY ACHIEVING A POSITIVE CASH FLOW AND PROFITABILITY FOR TWO CONSECUTIVE QUARTERS AND THE SECOND AND THIRD INSTALLMENTS WILL VEST ON THE FIRST AND SECOND ANNIVERSARIES OF SUCH DATE, RESPECTIVELY, PROVIDED THAT IN NO CASE WILL VESTING BEGIN LATER THAN DECEMBER 14, 2005. **Intentional misstatements or omissions of facts constitute Federal Criminal /s/ ABDO H. KHOURY May 15, 2001 Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). -------------------- ------------ Abdo H. Khoury Date **Signature of Reporting Person 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. SEC 1474 (3-99) 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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