1 ---------------------------------- OMB APPROVAL ---------------------------------- OMB Number 3235-0287 Expires: February 1, 2001 Estimated average burden hours per response ......0.5 hours ---------------------------------- 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(f) of the Investment Company Act of 1940 FORM 4 [_] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). ________________________________________________________________________________ 1. Name and Address of Reporting Person* CLEMENS PETER A. - -------------------------------------------------------------------------------- (Last) (First) (Middle) c/o Halsey Drug Co. 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 7/99 ________________________________________________________________________________ 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 title below) [_] Other (specify below) Vice President and Chief Financial Officer ________________________________________________________________________________ ________________________________________________________________________________ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ________________________________________________________________________________ 6. 4. 5. Owner- Securities Acquired (A) or Amount of ship 3. Disposed of (D) Securities Form: 7. 2. Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of Transaction Code ------------------------------- Owned at End (D) or Indirect 1. Date (Instr. 8) (A) of Month Indirect Beneficial Title of Security (Month/ ------------ Amount or Price (Instr. 3 (I) Ownership (Instr. 3) Day/Year) Code V (D) and 4) (Instr.4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ 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) ________________________________________________________________________________ 10. 9. Owner- Number ship of Form 2. Deriv- of Conver- 5. 7. ative Deriv- 11. sion Number of Title and Amount Secur- ative Nature or Derivative 6. of Underlying 8. ities Secur- of Exer- 4. Securities Date Securities Price Bene- ity: In- cise 3. Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- action or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Code of(D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date (Instr. (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ 8) 4 and 5) Date Expira- Number ity Month (I) ship Security Secur- Day/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $1.404 3/10/98 A (1) 3/10/98 3/15/03 Stock 71,225 71,225 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $1.404 3/10/98 A (1) 3/10/98 3/15/05 Stock 10,101 10,101 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $2.279 3/10/98 A (1) 3/10/98 3/15/05 Stock 10,101 10,101 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $1.404 6/12/98 A4 (2) 6/12/98 3/15/03 Stock 17,121 17,121 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $1.404 6/12/98 A4 (2) 6/12/98 3/15/05 Stock 2,428 2,428 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $2.279 6/12/98 A4 (2) 6/12/98 3/15/05 Stock 2,428 2,428 D - ------------------------------------------------------------------------------------------------------------------------------------ Non-qualified Common Stock Options $2.375 2/19/98 A4 (3) 2/19/08 Stock 300,000 300,000 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $1.1312 4/1/99 A (2) 4/1/99 3/15/03 Stock 1,370 1,370 D - ------------------------------------------------------------------------------------------------------------------------------------ Non-qualified Common Stock Options $1.125 4/12/99 A (4) 3/8/00 3/8/09 Stock 100,000 100,000 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $2.4250 7/1/99 A (2) 7/1/99 3/15/03 Stock 647 647 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 August 9 , 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.