-----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, RJGmTTXlLqwkJTS4FpAgzgTAj+zVx7vvUib7t9uZWdfpy4SUmAERXDumoVx8+e/Z rwpKIoakLbc8A5w5qiq6RA== 0000912057-01-004879.txt : 20010214 0000912057-01-004879.hdr.sgml : 20010214 ACCESSION NUMBER: 0000912057-01-004879 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20001231 FILED AS OF DATE: 20010213 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: BILLSERV COM INC CENTRAL INDEX KEY: 0001088034 STANDARD INDUSTRIAL CLASSIFICATION: FUNCTIONS RELATED TO DEPOSITORY BANKING, NEC [6099] IRS NUMBER: 980190072 STATE OF INCORPORATION: NV FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: SEC FILE NUMBER: 000-30152 FILM NUMBER: 1536693 BUSINESS ADDRESS: STREET 1: 211 N LOOP 1604 STREET 2: SUITE 100 CITY: SAN ANTONIO STATE: TX ZIP: 78232 BUSINESS PHONE: 2104025000 MAIL ADDRESS: STREET 1: 211 N LOOP 1604 STREET 2: STE 100 CITY: SAN ANTONIO STATE: TX ZIP: 78232 COMPANY DATA: COMPANY CONFORMED NAME: JONES DAVID S CENTRAL INDEX KEY: 0001089347 STANDARD INDUSTRIAL CLASSIFICATION: [] OTHER FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 211 N LOOP STREET 2: 1604 E. SUITE 100 CITY: SAN ANTONIO STATE: TX ZIP: 78232 MAIL ADDRESS: STREET 1: 211 N., LOOP STREET 2: 1604 E. SUITE 100 CITY: SAN ANTONIO STATE: TX ZIP: 78232 5 1 a2038311z5.txt FORM 5
- -------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION ----------------------------- FORM 5 WASHINGTON, D.C. 20549 OMB APPROVAL - -------- ----------------------------- / / CHECK BOX IF NO LONGER ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OMB NUMBER: 3235-0362 SUBJECT TO SECTION 16. EXPIRES: SEPTEMBER 30, 1998 FORM 4 OR FORM 5 OBLI- Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, ESTIMATED AVERAGE BURDEN GATIONS MAY CONTINUE. Section 17(a) of the Public Utility Holding Company Act of 1935 or HOURS PER RESPONSE .... 1.0 SEE INSTRUCTION 1(b). Section 30(f) of the Investment Company Act of 1940 ----------------------------- / / FORM 3 HOLDINGS REPORTED /X/ FORM 4 TRANSACTIONS REPORTED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) X Director 10% Owner Jones David S. Billserv.com, Inc. BLLS ---- ---- - ------------------------------------------------------------------------------------------- X Officer (give Other (specify (Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- title ---- below) Number of Reporting Month/Year below) Person (Voluntary) EVP 211 North Loop 1604 E, Ste 100 2000 -------------------------- - ------------------------------------------- ------------------------------------------------------------- (Street) 5. If Amendment, 7. Individual or Joint/Group Reporting Date of Original (check applicable line) (Month/Year) X Form Filed by One Reporting Person --- Form filed by More than One Reporting Person San Antonio, Texas 78232 --- - ------------------------------------------------------------------------------------------------------------------------------------ (City) (State) (Zip) TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) or 5. Amount of 6. Owner- 7. Nature of (Instr. 3) action tion Disposed of (D) Securities ship Indirect Date Code (Instr. 3, 4 and 5) Beneficially Form: Beneficial (Instr. 8) Owned at Direct Ownership (Month/ end of (D) or (Instr. 4) Day/ ------------------------------ Issuer's Indirect Year) Amount (A) or Price Fiscal Year (I) (D) (Instr. 3 (Instr. 4) and 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ *If the form is filed by more than one reporting person, see instruction 4(b)(v). (Over) SEC 2270 (7/97) 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 CONTROL NUMBER.
FORM 5 (CONTINUED) TABLE II - DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED (e.g., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) - ------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative Security 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- (Instr. 3) sion of action action Derivative cisable and Exercise Date Code Securities Ac- Expiration Price of (Month/ (Instr. 8) quired (A) or Date Deriv- Day/ Disposed of Month/Day/ ative Year) (D) Year) Security (Instr. 3, 4, and 5) -------------------- Date Expir- ---------------------- Exer- ation cisable Date (A) (D) - ------------------------------------------------------------------------------------------------------------------------ Stock Option $2.063 12/28/00 A4 75,000 (1) 12/28/10 - ------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------ 7. Title and Amount of Under- 8. Price 9. Number 10. Owner- 11. Na- lying Securities of of Deriv- ship ture of (Instr. 3 and 4) Deriv- ative of Indirect ative Secur- Deriv- Bene- Secur- ities ative ficial ity Bene- Secur- Owner- (Instr. ficially ity: ship 5) Owned Direct (Instr. 4) - ------------------------------------ at End (D) of Year or In- Amount or (Instr. 4) direct Title Number of (I) Shares (Instr. 4) - ------------------------------------------------------------------------------------------ Common 75,000 190,000 D - ------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------ Explanation of Responses: (1) 25,000 shares on 12/28/01, 12/28/02, 12/28/03 /s/ David S. Jones 2-12-01 ----------------------------------- ----------- **Intentional misstatements or omissions of facts constitute **Signature of Reporting Person Date 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. Page 2 SEC 2270 (7-97)
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