1 ------------------------- OMB APPROVAL OMB Number 3235-0287 Expires: February 1, 2001 Estimated average burden hours per response....1.0 ------------------------- 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(1) 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). ________________________________________________________________________________ 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 (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year 05/01 ________________________________________________________________________________ 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 & Chief Financial Officer ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================ Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. SFC 1474 (3/91) (Print or Type Responses) * See footnote 2 on Table II (Over)
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) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ==================================================================================================================================== 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 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 - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $ .6258 01/01/01 A (5) 10/01/01 3/15/03 Stock 2,477 748,359 D - ------------------------------------------------------------------------------------------------------------------------------------ 5% Convertible Senior Secured Common Debentures $ 1.03 04/01/01 A (5) 04/01/01 3/15/03 Stock 1,505 749,864 D ==================================================================================================================================== 3 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. By: /S/ Peter A. Clemens May 10, 2001 - --------------------------------------------- ----------------------- Peter A. Clemens 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 SPACEED PROVIDED IS INSUFFICIENT, SEE INSTRUCTION 6 FOR PROCEDURE.