-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, ESY4GOLnoTKLEoo5EmNaGCriQrmkRJwG39dgl6yDIfzEV5CNrQLAJw8VUak+gApu BZ7jsPbcXYLMG+GeFtfnDA== 0000351717-98-000002.txt : 19980115 0000351717-98-000002.hdr.sgml : 19980115 ACCESSION NUMBER: 0000351717-98-000002 CONFORMED SUBMISSION TYPE: SC 13G/A PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 19980114 SROS: NASD SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: CPAC INC CENTRAL INDEX KEY: 0000351717 STANDARD INDUSTRIAL CLASSIFICATION: SPECIAL INDUSTRY MACHINERY, NEC [3559] IRS NUMBER: 160961040 STATE OF INCORPORATION: NY FISCAL YEAR END: 0331 FILING VALUES: FORM TYPE: SC 13G/A SEC ACT: SEC FILE NUMBER: 005-33289 FILM NUMBER: 98506363 BUSINESS ADDRESS: STREET 1: 2364 LEICESTER RD CITY: LEICESTER STATE: NY ZIP: 14481 BUSINESS PHONE: 7163823223 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: CPAC INC CENTRAL INDEX KEY: 0000351717 STANDARD INDUSTRIAL CLASSIFICATION: SPECIAL INDUSTRY MACHINERY, NEC [3559] IRS NUMBER: 160961040 STATE OF INCORPORATION: NY FISCAL YEAR END: 0331 FILING VALUES: FORM TYPE: SC 13G/A BUSINESS ADDRESS: STREET 1: 2364 LEICESTER RD CITY: LEICESTER STATE: NY ZIP: 14481 BUSINESS PHONE: 7163823223 SC 13G/A 1 SCHEDULE 13G AMENDMENT NO. 15 UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 SCHEDULE 13G/A UNDER THE SECURITIES EXCHANGE ACT OF 1934 (AMENDMENT NO. FIFTEEN (15)) CPAC, Inc., 2364 Leicester Road, Leicester, New York 14481 ---------------------------------------------------------- (Name of Issuer) Common, Voting Stock ($.01 par value) ------------------------------------ (Title of Class of Securities) 126145101 -------- (CUSIP Number) Check the following box if a fee is being paid with this statement [ ]. (A fee is not required only if the filing person: (1) has a previous statement on file reporting beneficial ownership of more than five percent of the class of securities described in Item 1; and (2) has filed no amendment subsequent thereto reporting beneficial ownership of five percent or less of such class.) (See Rule 13d-7). *The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter the disclosures provided in a prior cover page. The information required in the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 ("Act") or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes). CUSIP NO. 126145101 SCHEDULE 13G/A 1.Name of Reporting Person S.S. or I.R.S. Identification No. of Above Person THOMAS N. HENDRICKSON ------------------------------------------------------------ 2.Check the Appropriate Box if a Member of a Group* N/A (a) [ ] (b) [ ] 3.SEC use only ------------------------------------------------ 4.Citizenship or Place of Organization UNITED STATES ----------------------- Number of Shares Beneficially Owned by Each Reporting Person With: 5.Sole Voting Power 447,413 ------------------------------------------ 6.Shared Voting Power 24,364 ---------------------------------------- 7.Sole Dispositive Power 447,413 ------------------------------------- 8.Shared Dispositive Power 24,364 ----------------------------------- 9.Aggregate Amount Beneficially owned by Each Reporting Person 471,777 ------- 10.Check Box if the Aggregate Amount in Row 9 Excludes Certain Shares* [ ] (AGGREGATE IN ROW 9 EXCLUDES NO SHARES) ---------------------------------------------------- 11. Percent of Class Represented by Amount in Row 9 6.59% ------------ 12. Type of Reporting Person* INDIVIDUAL ---------------------------------- *SEE INSTRUCTION BEFORE FILLING OUT! GENERAL INSTRUCTIONS A. Statements containing the information required by this schedule shall be filed not later than February 14 following the calendar year covered by the statement or within the time specified in Rule 13d-1(b)(2), if applicable. B. Information contained in a form which is required to be filed by rules under section 13(f) (15 U.S.C. 78m(f)) for the same calendar year as that covered by a statement on this schedule may be incorporated by reference in response to any of the items of this schedule. If such information is incorporated by reference in this schedule, copies of the relevant pages of such form shall be filed as an exhibit to this schedule. C. The item numbers and captions of the items shall be included but the text of the items is to be omitted. The answers to the items shall be so prepared as to indicate clearly the coverage of the items without referring to the text of the items. Answer every item. If an item is inapplicable or the answer is in the negative, so state. ITEM 1. (a) Name of Issuer CPAC, Inc. -------------------- (b) Address of Issuer's Principal Executive Offices 2364 Leicester Road -------------------- Leicester, NY 14481 -------------------- ITEM 2. (a) Name of Person Filing Thomas N. Hendrickson --------------------- (b) Address of Principal Business Office or, if none, Residence 2364 Leicester Road -------------------- Leicester. NY 14481 -------------------- (c) Citizenship United States -------------------- (d) Title of Class of Securities Common, voting stock --------------------- ($.01 par value) -------------------- (e) CUSIP Number 126145101 -------------------- ITEM 3. IF THIS STATEMENT IS FILED PURSUANT TO RULE 13D-L(B), OR 13D-2(B), CHECK WHETHER THE PERSON FILING IS A: N/A --- (a) [ ] Broker or Dealer registered under Section 15 of the Act (b) [ ] Bank as defined in section 3(a)(6) of the Act (c) [ ] Insurance Company as defined in section 3(a)(19) of this act (d) [ ] Investment Company registered under section 8 of the Investment Company Act (e) [ ] Investment Adviser registered under section 203 of the Investment Advisers Act of 1940 (f) [ ] Employee Benefit Plan, Pension Fund which is subject to the provisions of the Employee Retirement Income Security Act of 1974 or Endowment Fund; see Rule 13d-1(b)(1)(ii)(F) (g) [ ] Parent Holding Company, in accordance with Rule 13d- 1(b)(ii)(G) (Note: See Item 7) (h) [ ] Group, in accordance with Rule 13d-1(b)(1)(ii)(H) ITEM 4. OWNERSHIP If the percent of the class owned, as of December 31 of the year covered by the statement, or as of the last day of any month described in Rule 13d-1(b)(2), if applicable, exceeds five percent, provide the following information as of that date and identify those shares which there is a right to acquire. (a) Amount Beneficially Owned 471,777 Shares* ------------------------------------ (b) Percent of Class 6.59% ------------------------------------ (c) Number of shares as to which such person has: (i) sole power to vote or to direct the vote 447,413 ---------- (ii) shared power to vote or to direct the vote 24,364 ---------- (iii) sole power to dispose or to direct the disposition of 447,413 ---------- (iv) shared power to dispose or to direct the disposition of 24,364 ---------- *Amount listed in Item 4 (a) includes 24,364 shares owned by Mr. Hendrickson's spouse; 23,437 shares of CPAC's Common Stock subject to an option granted December 8, 1993, 46,875 shares of CPAC's Common Stock subject to an option granted February 9, 1994; and 82,500 shares of CPAC's Common Stock subject to an option granted February 8, 1996; which options are exercisable within sixty (60) days of December 31, 1997. Instruction: For computations regarding securities which represent a right to acquire an underlying security see Rule 13d-3(d)(1). ITEM 5. OWNERSHIP OF FIVE PERCENT OR LESS OF A CLASS N/A --- If this statement is being filed to report the fact that as of the date hereof the reporting person has ceased to be the beneficial owner of more than five percent of the class of securities, check the following [ ] Instruction: Dissolution of a group requires a response to this item. ITEM 6. OWNERSHIP OF MORE THAN FIVE PERCENT ON BEHALF OF ANOTHER PERSON N/A --- If any other person is known to have the right to receive or the power to direct the receipt of dividends from, or the proceeds from the sale of, such securities, a statement to that effect should be included in response to this item and, if such interest relates to more than five percent of the class, such person should be identified. A listing of the shareholders of an investment company registered under the Investment Company Act of 1940 or the beneficiaries of employee benefit plan, pension fund or endowment fund is not required. ITEM 7. IDENTIFICATION AND CLASSIFICATION OF THE SUBSIDIARY WHICH ACQUIRED THE SECURITY BEING REPORTED ON BY THE PARENT HOLDING COMPANY N/A --- If a parent holding company has filed this schedule, pursuant to Rule 13d- l(b)(ii)(G), so indicate under Item 3(g) and attach an exhibit stating the identity and the Item 3 classification of the relevant subsidiary. If a parent holding company has filed this schedule pursuant to Rule 13d-1(c), attach an exhibit stating the identification of the relevant subsidiary. ITEM 8. IDENTIFICATION AND CLASSIFICATION OF MEMBERS OF THE GROUP N/A --- If a group has filed this schedule pursuant to Rule 13d- I (b)(ii)(H), so indicate under Item 3(h) and attach an exhibit stating the identity and Item 3 classification of each member of the group. If a group has filed this schedule pursuant to Rule 13d- I (c), attach an exhibit stating the identity of each member of the group. ITEM 9. NOTICE OF DISSOLUTION OF GROUP N/A --- Notice of dissolution of a group may be furnished as an exhibit stating the date of the dissolution and that all further filings with respect to transactions in the security reported on will be filed, if required, by members of the group, in their individual capacity. See Item 5. ITEM 10. CERTIFICATION The following certification shall be included if the statement is filed pursuant to Rule 13d-1(b): By signing below I certify that, to the best of my knowledge and belief, the securities referred to above were acquired in the ordinary course of business and were not acquired for the purpose of and do not have the effect of changing or influencing the control of the issuer of such securities and were not acquired in connection with or as a participant in any transaction having such purposes or effect. SIGNATURE After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct. January 14, 1998 -------------------------------------------- Date /s/ Thomas N. Hendrickson -------------------------------------------- THOMAS N. HENDRICKSON President and Chief Executive Officer -----END PRIVACY-ENHANCED MESSAGE-----