-----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, V2zkSYCJ9nVry4feGFQht0oUwIEZ9Q2DJ/ro9B9vTJnit+JKaTYFOqw130eIJdRj Dbgp22oe1JzH6D7qFflDfg== 0001015769-02-000365.txt : 20021106 0001015769-02-000365.hdr.sgml : 20021106 20021105174530 ACCESSION NUMBER: 0001015769-02-000365 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021105 FILED AS OF DATE: 20021106 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: LINTZ CAROL R CENTRAL INDEX KEY: 0001198700 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 5 MAIL ADDRESS: STREET 1: 49 CARLETON DR CITY: NEEDHAM STATE: MA ZIP: 02492 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: VERMONT PURE HOLDINGS LTD/DE CENTRAL INDEX KEY: 0001123316 STANDARD INDUSTRIAL CLASSIFICATION: WHOLESALE-GROCERIES & RELATED PRODUCTS [5140] IRS NUMBER: 030366218 STATE OF INCORPORATION: DE FISCAL YEAR END: 1031 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-31797 FILM NUMBER: 02810368 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 5 1 lintz5.txt
- - ---------------- U.S. SECURITIES AND EXCHANGE COMMISSION -------------------------- |F O R M 5| Washington, D.C. 20549 | OMB APPROVAL | - - ---------------- |------------------------- Check this box if ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP |OMB Number 3235-0362| [ ] no longer Subject |Expires: December 31, 2001| to Section 16. |Estimated average burden | [ ] Form 3 Holdings Reported |hours per response.....1.0| [ ] Form 4 Transactions Filed pursuant to Section 16(a) of the Securities Exchanged Act of 1934, --------------------------- Reported Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(f) of the Investment Company Act 1940 - - ---------------------------------------------------------------------------------------------------------------------------------- |1.Name and Address of Reporting Person* |2.Issuer Name and Ticker or Trading Symbol |6.Relationship of Reporting Person to | | | | Issuer (Check all Applicable) | |Lintz Carol R. |Vermont Pure Holdings, LTD (Amex: VPS | | | | | X Director 10% Owner | |----------------------------------------|------------------------------------------------|--- --- | | (Last) (First) (MI)|3.IRS or Soc. Sec. No. |4.Statement for Month/ | Officer Other | | | of Reporting Person | Year |---(give title below) ---(Specify below)| | 49 Carteton | (Voluntary) | | | | | | November 2002 | | | | | | | |----------------------------------------| |------------------------|----------------------------------------| | (Street) | |5.If Amendment, Date of |7. Individual or Joint/Group Filing | | | n/a | Original (Month/Year) | (Check Applicable Line) | | Needham MA 02492 | | | | | | | n/a | X Form filed by One Reporting Person | | | | |--- | | | | | Form filed by More than One | | | | |--- Reporting Person | |----------------------------------------------------------------------------------------------------------------------------------| | (City) (State) (Zip) | | TABLE I - Non-Derivative Securities Acquired, Disposed of or Beneficially Owned | |----------------------------------------------------------------------------------------------------------------------------------| |1.Title of Security |2.Transac- |3.Trans. |4.Security Acquired (A) or |5.Amount of |6. |7.Nature of Indirect| | (Instr. 3) | tion Date | Code | Disposed of (D) | Securities |Own.| Beneficial | | |(Mon/Day/Yr)|(Instr.8)| (Instr. 3, 4 & 5) | Beneficially |Form| Ownership | | | | | | Owned at End of|(D) | (Instr. 4) | | | | |-------------------------------| Issuer's |or | | | | | | |(A) | | Fiscal Year |(I) | | | | | | Amount |(D) | Price | (Instr. 3 & 4) | | | |-------------------------------|------------|---------|----------------|----|---------|-----------------|----|--------------------| | | | | | | | | | | |-------------------------------|------------|---------|----------------|----|---------|-----------------|----|--------------------| |Common Stock | | | | | | 3,017 | D | N/A | | | | | | | | | | | |-------------------------------|------------|---------|----------------|----|---------|-----------------|----|--------------------| | | | | | | | | | | | | | | | | | | | | |-------------------------------|------------|---------|----------------|----|---------|-----------------|----|--------------------| | | | | | | | | | | | | | | | | | | | | |-------------------------------|------------|---------|----------------|----|---------|-----------------|----|--------------------| | | | | | | | | | | | | | | | | | | | | |-------------------------------|------------|---------|----------------|----|---------|-----------------|----|--------------------| | | | | | | | | | | | | | | | | | | | | |-------------------------------|------------|---------|----------------|----|---------|-----------------|----|--------------------| | | | | | | | | | | | | | | | | | | | | |-------------------------------|------------|---------|----------------|----|---------|-----------------|----|--------------------| Reminder: Report on a separate line for each class securities owned directly or indirectly. SEC 1474 (3-99) *If the form is filed by more than one reporting person, see Instruction 4(b)(v). PAGE: 1 OF 2
FORM 5 (continued) TABLE II - Derivative Securities Acquired, Disposed of, Beneficially Owned (e.g., puts, calls, warrants, options, convertible security) - ------------------------------------------------------------------------------------------------------------------------------------ |1.Title of|2.Conver-|3. |4.Tran- |5.Number of |6.Date |7.Title and Amount |8.Price of|9.Number |10. |11.Nature | |Derivative|sion or |Trans| saction| Derivative |Exercisable| of Underlying |Derivative| of |Own.| of | |Security |Exercise |Date | Code | Securities |and | Securities |Security |Derivative|Form|Indirect | |(Instr. 3)|Price of |(Mon/|(Instr.8)| Acquired (A) or |Expiration | (Instr. 3 & 4) |(Instr. 5)|Securities|of |Beneficial| | |Deriva- | Day/| | Disposed of (D) |Date | | |Benefi- |Deri|Ownership | | |tive |Year)| | (Instr. 3, 4 & 5) |(Month/Day/| | |cially |Sec.|(Instr. 4)| | |Security | | | | Year) | | |Owned at |Dir.| | | | | | | |-----------|---------------------| |End of |(D) | | | | | | | | | | |Amount or | |Year |or | | | | | | |---------------------|Date |Exp. | Title |Number of | |(Instr. 4)|Ind.| | | | | | | (A) | (D) |Exbl.|Date | |Shares | | |(I) | | |----------|---------|-----|---------|----------|----------|-----|-----|----------|----------|----------|----------|----|----------| | | | | | | | | | | | | | | | |----------|---------|-----|---------|----------|----------|-----|-----|----------|----------|----------|----------|----|----------| |Common |$3.65 |Nov. | A | A | |Nov. |Nov. |Common | 5,000 | | 35,000 | D | N/A | |Stock | |01, | | | |01, |01 |Stock | | | | | | |Option | |2001 | | | |2002 |2011 | | | | | | | |----------|---------|-----|---------|----------|----------|-----|-----|----------|----------|----------|----------|----|----------| |Common |$4.98 | | | | |Jan. |Jan. |Common | 5,000 | | 35,000 | D | N/A | |Stock | | | | | |01, |01 |Stock | | | | | | |Option | | | | | |2003 |2012 | | | | | | | |----------|---------|-----|---------|----------|----------|-----|-----|----------|----------|----------|----------|----|----------| |Common |$2.60 | | | | |Mar. |Mar. |Common |20,000 | | 20,000 | D | N/A | |Stock | | | | | |27, |27 |Stock | | | | | | |Option | | | | | |2002 |2011 | | | | | | | |----------|---------|-----|---------|----------|----------|-----|-----|----------|----------|----------|----------|----|----------| Explanation of Responses: **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). /s/ Bruce S. MacDonald ______________________________________ Bruce S. MacDonald Date November 5, 2002 **Signature of Reporting Person Note: File three copies of this form, one of which must be manually signed. If space provided is insufficient, see Instruction 6 for procedure. SEC 1474 (3-99) Potential persons who are to respond to the collections of information contained in this form are not required to respond unless the form displays a currently valid OMD Number PAGE: 2 OF 2
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