-----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, GHPSx9cjYXFXvprkqib4jn79Xj/HEeQI3Epn+RJVdbn4ylymv2j083E1CoRTHv3P 3rG5gnVuPqEx1lCTldireA== 0001116502-01-000100.txt : 20010131 0001116502-01-000100.hdr.sgml : 20010131 ACCESSION NUMBER: 0001116502-01-000100 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20010120 FILED AS OF DATE: 20010130 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: UNIVERSAL BEVERAGES HOLDINGS CORP CENTRAL INDEX KEY: 0001057909 STANDARD INDUSTRIAL CLASSIFICATION: WHOLESALE-GROCERIES & RELATED PRODUCTS [5140] IRS NUMBER: 650805935 STATE OF INCORPORATION: FL FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: SEC FILE NUMBER: 000-30363 FILM NUMBER: 1519345 BUSINESS ADDRESS: STREET 1: 7563 PHILIPS HWY STREET 2: SUITE 110 CITY: JACKSONVILLE STATE: FL ZIP: 32256 BUSINESS PHONE: (904) 296-7500 MAIL ADDRESS: STREET 1: 7563 PHILIPS HWY STREET 2: SUITE 110 CITY: JACKSONVILLE STATE: FL ZIP: 32256 COMPANY DATA: COMPANY CONFORMED NAME: RIPLEY CARLOS L CENTRAL INDEX KEY: 0001133450 STANDARD INDUSTRIAL CLASSIFICATION: [] DIRECTOR IRS NUMBER: 650805935 STATE OF INCORPORATION: FL FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 BUSINESS ADDRESS: STREET 1: 3915 VILLAGE WELL CITY: HUMBLE STATE: TX ZIP: 77396 BUSINESS PHONE: 9042967500 MAIL ADDRESS: STREET 1: 3915 VILLAGE WELL CITY: HUMBLE STATE: TX ZIP: 77396 3 1 0001.txt INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES ---------------------------- OMB APPROVAL OMB Number: 3235-0104 Expires: December 31, 2001 Estimated average burden hours per response. . . 0.5 ---------------------------- U.S. SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM 3 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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 ________________________________________________________________________________ 1. Name and Address of Reporting Person* Ripley Carlos L. - -------------------------------------------------------------------------------- (Last) (First) (Middle) 3915 Village Well - -------------------------------------------------------------------------------- (Street) Humble, TX 77396 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Date of Event Requiring Statement (Month/Day/Year) 01/20/01 ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ###-##-#### ________________________________________________________________________________ 4. Issuer Name and Ticker or Trading Symbol Universal Beverages Holdings Corporation ("UVBV") ________________________________________________________________________________ 5. Relationship of Reporting Person to Issuer (Check all applicable) [X] Director [_] 10% Owner [_] Officer (give title below) [_] Other (specify below) ________________________________________________________________________________ 6. If Amendment, Date of Original (Month/Day/Year) ________________________________________________________________________________ 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 Beneficially Owned ================================================================================
3. Ownership Form: 2. Amount of Securities Direct (D) or 1. Title of Security Beneficially Owned Indirect (I) 4. Nature of Indirect Beneficial Ownership (Instr. 4) (Instr. 4) (Instr. 5) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 111,600 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* If the Form is filed by more than one Reporting Person, see Instruction 5(b)(v). Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Print of Type Responses) (Over) FORM 3 (continued) Table II -- Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
5. Owner- 3. Title and Amount of Securities ship Underlying Derivative Security Form of 2. Date Exercisable (Instr. 4) Derivative and Expiration Date --------------------------------- 4. Conver- Security: (Month/Day/Year) Amount sion or Direct 6. Nature of ---------------------- or Exercise (D) or Indirect Date Expira- Number Price of Indirect Beneficial 1. Title of Derivative Exer- tion of Derivative (I) Ownership Security (Instr. 4) cisable Date Title Shares Security (Instr. 5) (Instr. 5) - ------------------------------------------------------------------------------------------------------------------------------------ Series B Convertible Preferred 3/29/00 Common Stock 50,000 1-for-2 1/2 D - ------------------------------------------------------------------------------------------------------------------------------------ $3.00 3/29/01* 3/31/02 Common Stock 40,000 $3.00 D - ------------------------------------------------------------------------------------------------------------------------------------ $3.00 3/29/01* 3/31/02 Common Stock 40,000 $5.00 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: * These Warrants are exercisable upon the earlier of one year from the date of issuance (March 29, 2000) or upon the effectiveness of a registration statement filed by the Company which registers the shares of common stock underlying these Warrants. /s/ Carlos L. Ripley 01/25/01 - --------------------------------------------- ----------------------- **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. Page 2 -----END PRIVACY-ENHANCED MESSAGE-----