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