-----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, I+wJlcilC53zzCoBN/YHFwBWbF/mgx1VGUDrWrLKZ9DKXv1cvmD9PctPObF+qlFp dSE+Stof8SWrEHWJaFfN2A== /in/edgar/work/0000950135-00-004612/0000950135-00-004612.txt : 20001017 0000950135-00-004612.hdr.sgml : 20001017 ACCESSION NUMBER: 0000950135-00-004612 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20001005 FILED AS OF DATE: 20001016 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: VERMONT PURE HOLDINGS LTD/DE CENTRAL INDEX KEY: 0001123316 STANDARD INDUSTRIAL CLASSIFICATION: [5140 ] IRS NUMBER: 030366218 STATE OF INCORPORATION: DE FISCAL YEAR END: 1031 FILING VALUES: FORM TYPE: 3 SEC ACT: SEC FILE NUMBER: 333-45226 FILM NUMBER: 741008 BUSINESS ADDRESS: STREET 1: RT 66 P O BOX C STREET 2: CAAMOUNT INDUSTRIAL PARK CITY: RANDOLPH STATE: VT ZIP: 05060 BUSINESS PHONE: 8027283600 MAIL ADDRESS: STREET 1: RT 66 P O BOX C STREET 2: CAAMOUNT INDUSTRIAL PARK CITY: RANDOLPH STATE: VT ZIP: 05060 FORMER COMPANY: FORMER CONFORMED NAME: VP MERGER PARENT INC DATE OF NAME CHANGE: 20000905 COMPANY DATA: COMPANY CONFORMED NAME: RAPAPORT ROSS S CENTRAL INDEX KEY: 0001125996 STANDARD INDUSTRIAL CLASSIFICATION: [ ]DIRECTOR IRS NUMBER: 066495498 FILING VALUES: FORM TYPE: 3 BUSINESS ADDRESS: STREET 1: C/O CRYSTAL ROCK SPRING WATER CO STREET 2: 1050 BUCKINGHAM STREET CITY: WATERTOWN STATE: CT ZIP: 06795 BUSINESS PHONE: 8005250070 3 1 b37066vpe3.txt VERMONT PURE HOLDINGS LTD. FORM 3 1 - -------- FORM 3 - -------- U.S. SECURITIES AND EXCHANGE COMMISSION WASHINGTON, DC 20549 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 2. Date of Event Requiring 4. Issuer Name and Ticker or 6. If Amendment, Date Statement Trading Symbol of Original ROSS S. RAPAPORT (Month/Day/Year) VERMONT PURE HOLDINGS,LTD. (VPS) (Month/Day/Year) - ---------------------------------------- 10/05/00 ---------------------------------- (Last) (First) (Middle) ---------------------------- 5. Relationship of Reporting ----------------------- c/o VERMONT PURE HOLDINGS, LTD. 3. IRS Identification Person to Issuer 7. Individual or Joint/ ROUTE 66, P.O. BOX C Number of Reporting (Check all applicable) Group Filing (Check CATAMOUNT INDUSTRIAL PARK Person, if an Entity X Director X 10% Owner applicable line) - ---------------------------------------- (Voluntary) ----- ----- Form filed by (Street) Officer Other ----- One Reporting ----- (give ----- (specify Person RANDOLPH VT 05060 title below) below) X Form filed by - ----------------------------------------------------------------------- ----- More than One (City) (State) (Zip) Reporting Person - ------------------------------------------------------------------------------------------------------------------------------------ TABLE I -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Amount of Securities 3. Ownership Form: 4. Nature of Indirect (Instr. 4) Beneficially Owned Direct (D) or Beneficial (Instr. 4) Indirect (I) Ownership (Instr. 5) (Instr. 5) - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 3,041,372 I(1) (1) - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 11,923 I(2) (2) - ------------------------------------------------------------------------------------------------------------------------------------ COMMON STOCK 11,923 I(3) (3) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over) (Print or Type Responses)
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FORM 3 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative Security 2. Date 3. Title and Amount of 4. Conver- 5. Owner- 6. Nature of Indirect (Instr. 4) Exercisable and Securities Underlying sion or ship Beneficial Ownership Expiration Date Derivative Security Exercise Form of (Instr. 5) (Month/Day/ (Instr. 4) Price of Deriv- Year) Deri- ative vative Security: Security Direct ------------------------------------------------- (D) or Date Expira- Amount or Indirect Exercis- tion Title Number (I) able Date of Shares (Instr. 5) - ------------------------------------------------------------------------------------------------------------------------------------ None - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------
Explanation of Responses: (1) Consists of shares held by the Reporting Person as Trustee of U/T/A dated 12/16/91 F/B/O Joan Baker et al. The Reporting Person disclaims beneficial ownership of these shares, and this report shall not be deemed an admission that the Reporting Person is the beneficial owner of such shares for purposes of Section 16 or for any other purpose. (2) Consists of shares held by the Reporting Person as Trustee of the John B. Baker Life Insurance Trust. The Reporting Person disclaims beneficial ownership of these shares, and this report shall not be deemed an admission that the Reporting Person is the beneficial owner of such shares for purposes of Section 16 or for any other purpose. (3) Consists of shares held by the Reporting Person as Trustee of the Peter K. Baker Life Insurance Trust. The Reporting Person disclaims beneficial ownership of these shares, and this report shall not be deemed an admission that the Reporting Person is the beneficial owner of such shares for purposes of Section 16 or for any other purpose. 3 Ross S. Rappaport 10/16/00 **Intentional misstatements or omissions of facts constitute Federal Criminal ------------------------------- ------------------ Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). **Signature of Reporting Person Date Note. File three copies of this form, one of which must be manually signed. Individually, as as Trustee U/T/A dated 12/16/91 F/B/O Joan Baker et If space provided is insufficient, See Instruction 6 for procedure. al., as Trustee of the John B. Baker Life Insurance Trust, and as Trustee of the Peter K. Baker Life Insurance Trust
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