1 QMB APPROVAL QMB Number 3235-0287 - ------ Expires: February 1, 2000 FORM 4 Estimated average burden: - ------ 0.5 hours U.S. SECURITIES AND EXCHANGE COMMISSION WASHINGTON, DC 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP / / Check box if no longer subject to Filed pursuant to Section 16(a) of the Securities Section 16. Form 4 Exchange Act of 1934, Section 17(a) of the or Form 5 obligations Public Utility Holding Company Act of 1935 may continue. See or Section 30(f) of the Investment Company Instruction 1(b). Act of 1940 - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person to Coujeevaram Srini Halsey Drug Co., Inc. Symbol: HDG Issuer - ------------------------------------------- -------------------------------------------- X Director 10% Owner (Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- --- Number of Reporting Month/Year Officer (give Other (Specify c/o Halsey Drug Co. 695 N. Perryville Rd. Person (Voluntary) 2/99 ---- title --- below) Bldg. 2 ------------------- below) - --------------------------------------------- -------------------- 5. If Amendment, __________________________________ (Street) Date of Original 7. Individual or Joint/Group Filing Rockford Illinois 61107 (Month/Year) (Check Applicable Line) - --------------------------------------------- X Form filed by One Reporting Person (City) (State) (Zip) ------------ --- 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. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature (Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In- Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct (Instr. 8) End of Month Direct Benefi- (Month/ (Instr. 3 and 4) (D) or cial Day/ --------------------------------------- Indirect Owner- Year) Code V Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ None - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ *If the Form is filed by more than one Reporting Person, see Instruction 4(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 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. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price Security sion or action action Derivative cisable and of Underlying of (Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv- Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative Deriv- Day/ Disposed of (D) (Month/Day/ Secur- ative Year) (Instr. 3, 4, Year) ity Security and 5) (Instr. 5) ----------------------------------- Date Expira- Amount or -------------------------- Exer- tion Title Number of Code V (A) (D) cisable Date Shares - ------------------------------------------------------------------------------------------------------------------------------------ Non-qualified stock options $1.225 2/18/99 A 10,000 (1) 2/19/09 Common 10,000 Stock - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ 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) - ------------------------------------------------------------------------------------------------------- 20,000 (D) - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- Explanation of Responses: (1) Option vest over twelve (12) months: 2,500 on 5/18/99; 2,500 on 8/18/99; 2,500 on 11/18/99 and final 2,500 options on 2/18/00. **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ Srini Conjeevaram March 9, 1999 See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------- ------------- **Signature of Reporting Date Person 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)