1 - -------- FORM 3 - -------- 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 Shroff Zubeen Statement Trading Symbol of Original - ---------------------------------------- (Month/Day/Year) Halsey Drug Co., Inc. (HDG) (Month/Day/Year) (Last) (First) (Middle) 6-30-98 ------------------------------ 610 Fifth Avenue, Rockefeller Center ---------------------------- 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 __ Form filed by One New York, New York 10020 ___ Officer _X_ Other Reporting Person - -------------------------------------- ---------------------------- (give title below) (specify below) __ Form filed by More (City) (State) (Zip) than One Reporting General partner of Galen Partners Person III, L.P. which together with affiliated entities owns convertible debentures exercisable for approximately fifth 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. 4) (Instr. 5) - ----------------------------------------------------------------------------------------------------------------------------------- None - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- *If the form is filed by more than one Reporting Person, see Instruction 5(b)(v). Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over) (Print or Type Responses) (Bulletin No. 177, 10-15-97) 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 Options (Right to Buy) * * Common Stock 10,000 $ 2 3/8 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: *Date of grant of stock option June 30, 1998; Date Exercisable and Expiration Date to be determined. /s/ Zubeen Shroff July 9, 1998 **Intentional misstatements or omissions of facts constitute Federal Criminal ------------------------------- ------------ Violations. **Signature of Reporting Person Date See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). 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. (Bulletin No. 177, 10-15-97)