1 OMB APPROVAL ------------------------- OMB Number: 3235-0287 ------------------------- Expires: February 1, 2001 ------------------------- Estimated average burden hours per response...1.0 ------------------------- FORM 4 UNITED STATES 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 [_] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). (Print or Type Responses) ________________________________________________________________________________ 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. Symbol: HDGC - -------------------------------------------------------------------------------- ________________________________________________________________________________ 3. IRS or Social Security Number of Reporting Person, if an entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year 10/00 - -------------------------------------------------------------------------------- ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ================================================================================ 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) [X] Director [_] 10% Owner [X] Officer (give title below) [_] Other (specify below) Vice President and Chief Financial Officer ________________________________________________________________________________ 7. Individual or Joint/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 ================================================================================ (Over) 1 of 2
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 Indirect 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) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ==================================================================================================================================== Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (over) *See Footnote 2 on Table II 2 FORM 4 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================ 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 (10,791 shares of which are presently exercisable at $1.404 per share and 10,526 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 (2,594 shares of which are presently exercisable at $1.404 per share and 2,530 shares of which are presently exercisable at $2.279 per share). (3) Options vest quarterly, with 25,000 options vesting every quarter effective May 1, 1998. (4) Options vest 25% annually. (5) Certain quarterly interest payments are paid in the form of convertible debentures. /s/ Peter A. Clemens November 1, 2000 - --------------------------------------------- ----------------------- Peter A. Clemens 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.
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 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $1.404 3/10/98 A (1) 3/10/98 3/15/05 Stock 10,791 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $2.279 3/10/98 A (1) 3/10/98 3/15/05 Stock 10,526 92,542 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $1.404 6/12/98 A (2) 6/12/98 3/15/03 Stock 17,121 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $1.404 6/12/98 A (2) 6/12/98 3/15/05 Stock 2,594 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Warrants $2.279 6/12/98 A (2) 6/12/98 3/15/05 Stock 2,530 114,787 D - ------------------------------------------------------------------------------------------------------------------------------------ Non-qualified Common Stock Options $2.375 2/19/98 A (3) 2/19/08 Stock 300,000 414,787 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $1.1312 4/1/99 A (5) 4/1/99 3/15/03 Stock 1,370 D - ------------------------------------------------------------------------------------------------------------------------------------ Non-qualified Common Stock Options $1.125 4/12/99 A (4) 4/12/00 4/12/09 Stock 100,000 516,157 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $2.4250 7/1/99 A (5) 7/1/99 3/15/03 Stock 647 516,804 D - ------------------------------------------------------------------------------------------------------------------------------------ Non-qualified Common Stock Options $1.875 2/17/00 A (4) 2/17/01 2/17/10 Stock 125,000 641,804 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $1.722 4/1/00 A (5) 4/1/00 3/15/03 Stock 923 642,727 D - ------------------------------------------------------------------------------------------------------------------------------------ Non-qualified Common Stock Options $1.1125 6/29/00 A (4) 6/29/01 6/29/10 Stock 100,000 742,727 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $1.1125 7/1/00 A (5) 7/01/00 3/15/03 Stock 1,446 744,173 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $.9071 10/1/00 A (5) 10/01/00 3/15/03 Stock 1,709 745,882 D ====================================================================================================================================