1 ------------------------------ OMB APPROVAL ------------------------------ OMB Number 3235-0287 Expires: February 1, 2000 Estimated average burden 0.5 hours ------------------------------ U.S. SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 4 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 [_] Check 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* Heitmeyer Stephanie K. - -------------------------------------------------------------------------------- (Last) (First) (Middle) c/o Halsey Drug Co., Inc. 17759 State Route 66 - -------------------------------------------------------------------------------- (Street) Ft. Jennings Ohio 45844 - -------------------------------------------------------------------------------- (City) (State) (Zip) - -------------------------------------------------------------------------------- 2. Issuer Name and Ticker or Trading Symbol Halsey Drug Co., Inc. Symbol: HDG - -------------------------------------------------------------------------------- 3. IRS or Social Security Number of Reporting Person (Voluntary) - -------------------------------------------------------------------------------- 4. Statement for Month/Year 10/99 - -------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Year) - -------------------------------------------------------------------------------- 6. Relationship of Reporting Person to Issuer (Check all applicable) [_] Director [_] 10% Owner [X] Officer (give title below) [_] Other (specify below) Vice-President (Sales) - -------------------------------------------------------------------------------- 7. Individual or Group Filing (Check Applicable Line) [X] Form filed by one Reporting Person [_] Form filed by more than one Reporting Person - -------------------------------------------------------------------------------- - -------------------------------------------------------------------------------- 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. Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of 2. Code ------------------------------------ Owned at End (D) or In-direct 1. Transaction (Instr. 8) (A) of Month Indirect Beneficial Title of Security Date ------------- Amount or Price (Instr. 3 (I) Ownership (Instr. 3) (Month/Day/Year) Code V (D) and 4) (Instr.4) (Instr. 4) - --------------------------------------------------------------------------------------------------------------------------------- Common Stock 7/1/99 P 274 A $1.1312 D - --------------------------------------------------------------------------------------------------------------------------------- Common Stock 7/1/99 P 127 A $2.4250 D - --------------------------------------------------------------------------------------------------------------------------------- Common Stock 10/1/99 P 134 A 2.3063 535 D ================================================================================================================================= Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (over) * If this form is filed by more than one person, see Instruction 4(b)(v). SFC 1474 (3/91)
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 14,245 14,245 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $ 1.404 3/10/98 A (1) 3/10/98 3/15/05 Stock 2,020 2,020 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $ 2.279 3/10/98 A (1) 3/10/98 3/15/05 Stock 2,020 2,020 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $ 1.404 6/12/98 A4 (2) 6/12/98 3/15/03 Stock 3,424 3,424 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $ 1.404 6/12/98 A4 (2) 6/12/98 3/15/05 Stock 485 485 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $ 2.279 6/12/98 A4 (2) 6/12/98 3/15/05 Stock 485 485 D - ------------------------------------------------------------------------------------------------------------------------------------ Qualified Common Stock Options $ 2.50 5/29/98 A4 (3) 5/29/08 Stock 40,000 40,000 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 (2,020 shares of which are presently exercisable at $1.404 per share and 2,020 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 (485 shares of which are presently exercisable at $1.404 per share and 485 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 annually, with 10,000 options vesting every quarter effective 5/1/99. /s/ Stephanie K. Heitmeyer November 9, 1999 - --------------------------------------------- ----------------------- Signature of Reporting Person Date 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 space provided is insufficient, see Instruction 6 for procedure. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number.