1 FORM 4 [ ] CHECK THIS BOX IF NO LONGER SUBJECT TO SECTION 16. FORM 4 OR FORM 5 OBLIGATIONS MAY CONTINUE. SEE INSTRUCTION 1(b). U.S. SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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(1) OF THE INVESTMENT COMPANY ACT OF 1940 OMB APPROVAL OMB NUMBER 3235-0287 EXPIRES: FEBRUARY 1, 2001 ESTIMATED AVERAGE BURDEN HOURS PER RESPONSE......0.5 1. Name and Address of Reporting Person CLEMENS PETER A. - ------------------------------------------------------------------- (LAST) (FIRST) (MIDDLE) C/O HALSEY DRUG CO., INC. 695 N. PERRYVILLE RD. BLDG. 2 - ------------------------------------------------------------------- (STREET) ROCKFORD ILLINOIS 61107 - ------------------------------------------------------------------- (CITY) (STATE) (ZIP) 2. ISSUER NAME AND TICKER OR TRADING SYMBOL HALSEY DRUG CO., INC. HDG - ------------------------------------------------------------------- 3. IRS OR SOCIAL SECURITY NUMBER OF REPORTING PERSON (VOLUNTARY) - ------------------------------------------------------------------- 4. STATEMENT FOR MONTH/YEAR 4/99 - ------------------------------------------------------------------- 5. IF AMENDMENT, DATE OF ORIGINAL (MONTH/YEAR) - ------------------------------------------------------------------- 6. RELATIONSHIP OF REPORTING PERSON TO ISSUER (CHECK ALL APPLICABLE) X DIRECTOR 10% OWNER -- -- X OFFICER (GIVE OTHER (SPECIFY -- -- TITLE BELOW) BELOW) VICE PRESIDENT AND CHIEF FINANCIAL OFFICER - ------------------------------------------------------------------- TABLE I-- 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. OWNER 7. NATURE OF (INSTR. 3) ACTION ACTION OR DISPOSED OF (D) SECURITIES SHIP FORM: INDIRECT DATE CODE (INSTR. 3, 4, AND 5) BENEFICIALLY DIRECT (D) BENEFICIAL (INSTR. 8) OWNED AT OR INDIRECT OWNERSHIP (MONTH/ END OF MONTH (I) (INSTR. 4) DAY/ (INSTR. 3 AND (INSTR. 4) YEAR) 4) CODE V AMOUNT (A) OR PRICE (D) COMMON STOCK 10/1/98 A* 842 A* $1.8406 D COMMON STOCK 1/1/99 A* 1,333 A* $1.1625 D 2,175 REMINDER: REPORT ON A SEPARATE LINE FOR EACH CLASS OF SECURITIES BENEFICIALLY OWNED DIRECTLY OR INDIRECTLY. * SEE FOOTNOTE (2) TO TABLE II. (OVER)
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. 3. 4. 5. 6. SECURITY CONVER- TRANS- TRANS- NUMBER OF DATE EXER- (INSTR. 3) SION OR ACTION ACTION DERIVATIVE CISABLE AND EXERCISE DATE CODE SECURITIES AC- EXPIRATION PRICE OF (MONTH/ (INSTR. QUIRED (A) OR DATE DERIV- DAY/ 8) DISPOSED OF (D) (MONTH/DAY/ ATIVE YEAR) (INSTR. 3, 4, AND YEAR) SECURITY 5) DATE EXPIR- EXER ATION CISABLE- DATE CODE V (A) (D) - ------------------------------------------------------------------------------------------------------------- 5% CONVERTIBLE SENIOR $1.404 3/10/98 A (1) 3/10/98 3/15/03 SECURED DEBENTURES - ------------------------------------------------------------------------------------------------------------- WARRANTS $1.404 3/10/98 A (1) 3/10/98 3/15/05 - ------------------------------------------------------------------------------------------------------------- WARRANTS $2.279 3/10/98 A (1) 3/10/98 3/15/05 - ------------------------------------------------------------------------------------------------------------- 5% CONVERTIBLE SENIOR $1.404 6/12/98 A4 (2) 6/12/98 3/15/03 SECURED DEBENTURES - ------------------------------------------------------------------------------------------------------------- WARRANTS $1.404 6/12/98 A4 (2) 6/12/98 3/15/05 - ------------------------------------------------------------------------------------------------------------- WARRANTS $2.279 6/12/98 A4 (2) 6/12/98 3/15/05 - ------------------------------------------------------------------------------------------------------------- NON-QUALIFIED STOCK OPTIONS $2.375 2/19/98 A4 (3) 2/19/08 - ------------------------------------------------------------------------------------------------------------- 5% CONVERTIBLE SENIOR $1.1312 4/1/99 A (2) 4/1/99 3/15/03 SECURED DEBENTURES - ------------------------------------------------------------------------------------------------------------- NON-QUALIFIED STOCK OPTIONS $1.125 4/12/99 A (4) 3/8/00 3/8/09 - ------------------------------------------------------------------------------------------------------------- 7. 8. PRICE 9. NUMBER 10. OWNER- 11. NATURE TITLE AND AMOUNT OF OF OF DERIV- SHIP OF UNDERLYING SECURITIES DERIV- ATIVE FORM OF INDIRECT (INSTR. 3 AND 4) ATIVE SECURITIES DE- BENEFICIAL SECURITY BENE- RIVATIVE OWNERSHIP (INSTR.5) FICIALLY SECURITY: OWNED AT DIRECT END (D) OR (INSTR. 4) OF MONTH INDIRECT (I) (INSTR. 4) (INSTR. 4) AMOUNT OR TITLE NUMBER OF SHARES - ------------------------------------------------------------------------------------------------- COMMON STOCK 71,225 71,225 D - ------------------------------------------------------------------------------------------------- COMMON STOCK 10,101 10,101 D - ------------------------------------------------------------------------------------------------- COMMON STOCK 10,101 10,101 D - ------------------------------------------------------------------------------------------------- COMMON STOCK 17,121 17,121 D - ------------------------------------------------------------------------------------------------- COMMON STOCK 2,428 2,428 D - ------------------------------------------------------------------------------------------------- COMMON STOCK 2,428 2,428 D - ------------------------------------------------------------------------------------------------- COMMON STOCK 300,000 300,000 D - ------------------------------------------------------------------------------------------------- COMMON STOCK 1,370 1,370 D - ------------------------------------------------------------------------------------------------- COMMON STOCK 100,000 100,000 D - ------------------------------------------------------------------------------------------------- EXPLANATION OF RESPONSES: (1) PURCHASED IN CONNECTION WITH A PRIVATE OFFERING ON MARCH 10, 1998 CONSISTING OF A CONVERTIBLE DEBENTURE CONVERTIBLE AT ANY TIME AND STOCK PURCHASE WARRANTS (10,101 SHARES OF WHICH ARE PRESENTLY EXERCISABLE AT $1.404 PER SHARE AND 10,101 SHARES OF WHICH ARE PRESENTLY EXERCISABLE AT $2.279 PER SHARE). (2) ACQUIRED PURSUANT TO AN OPTION EXERCISE IN JUNE 1998, CONSISTING OF: (i) A CONVERTIBLE DEBENTURE, CONVERTIBLE AT ANY TIME; (ii) WARRANTS TO PURCHASE SHARES OF COMMON STOCK (2,428 SHARES OF WHICH ARE PRESENTLY EXERCISABLE AT $1.404 PER SHARE AND 2,428 SHARES OF WHICH ARE PRESENTLY EXERCISABLE AT $2.279 PER SHARE); AND (iii) CERTAIN INTEREST PAYMENTS PAYABLE QUARTERLY WHICH ARE PAID IN THE FORM OF SHARES OF COMMON STOCK OF THE ISSUER (SEE TABLE I). (3) OPTIONS VEST QUARTERLY, WITH 25,000 OPTIONS VESTING EVERY QUARTER EFFECTIVE MAY 1, 1998. (4) OPTIONS VEST 25% ANNUALLY, WITH 25,000 OPTIONS VESTING EVERY MARCH 8, BEGINNING MARCH 8, 2000. /s/ Peter A. Clemens May 6, 1999 ---------------------- ------------ NAME: PETER A. CLEMENS DATE SIGNATURE OF REPORTING PERSON INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACTS CONSTITUTE FEDERAL CRIMINAL VIOLATIONS. 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. IF SPACED PROVIDED IS INSUFFICIENT, SEE INSTRUCTION 6 FOR PROCEDURE.