1 --------------------------- OMB APPROVAL --------------------------- - -------- OMB Number: 3235-0104 FORM 3 Expires: September 30, 1998 - -------- Estimated average burden hours per response .... 0.5 --------------------------- U.S. SECURITIES AND EXCHANGE COMMISSION WASHINGTON, DC 20549 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 Conjeevaram Srini Statement Trading Symbol of Original - ---------------------------------------- (Month/Day/Year) Halsey Drug Co., Inc (HDG) (Month/Day/Year) (Last) (First) (Middle) 3-10-98 ------------------------------ 70 Hereford Road ---------------------------- 5. Relationship of Reporting 7. Individual or Joint/ - ---------------------------------------- 3. IRS or Social Security Person to Issuer Group Filing (Check (Street) Number of Reporting (Check all applicable) Applicable Line) Person (Voluntary) X Director ___ 10% Owner X Form filed by One Bronxville, New York 10708 ###-##-#### ___Officer X Other Reporting Person - -------------------------------------- ---------------------------- (give title below) (specify below) __Form filed by More (City) (State) (Zip) than One Reporting Person General Partner of Galen Partners III, L.P. which together with affiliated entities owns convertible debentures exercisable for approximately fifty percent (50%) of the common stock of Halsey Drug Co., Inc. - ----------------------------------------------------------------------------------------------------------------------------------- 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. 5) (Instr. 5) - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over) (Print or Type Responses) SEC 1473 (8/92) 2
FORM 3 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative Security 2. Date 3. Title and Amount of 4. Conver- 5. Owner- 6. Nature of Indirect (Instr. 4) Exercisable and Securities Underlying sion or ship Beneficial Ownership Expiration Date Derivative Security Exercise Form of (Instr. 5) (Month/Day/ (Instr. 4) Price of Deriv- Year) Deri- ative vative Security: Security Direct ------------------------------------------------- (D) or Date Expira- Amount or Indirect (I) Exercis- tion Title Number (Instr. 5) able Date of Shares - ------------------------------------------------------------------------------------------------------------------------------------ Stock Option * * Common Stock 10,000 $3.125 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: *Date of grant of stock option March 10, 1998; Date Exercisable and Expiration Date to be determined. /s/ SRINI CONJEEVARAM 3/18/1998 **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. Page 2 If space provided is insufficient, See Instruction 6 for procedure. SEC 1473 (8/92)