5 1 evansform5feb-2003.htm FORM 5 - RICHARD W. EVANS OMB APPROVAL

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UNITED STATES SECURITIES AND EXCHANGE COMMISSION

Washington, DC 20549

FORM 5

ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

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(h) of the Investment Company Act of 1940

|_| Check box if no longer subject to Section 16. Form 4 or Form 5 obligations

may continue. See Instruction 1(b).

|_| Form 3 Holdings Reported

|_| Form 4 Transactions Reported

______________________________________________________

1. Name and Address of Reporting Person*

Evans Richard W.

- --------------------------------------------------------------------------------

(Last) (First) (Middle)

c/o Coates International, Ltd.

2100 Highway #34 & Ridgewood Road

- --------------------------------------------------------------------------------

(Street)

Wall Township New Jersey 07719-9738

- --------------------------------------------------------------------------------

(City) (State) (Zip)

_______________________________________________________

2. Issuer Name and Ticker or Trading Symbol

Coates International, Ltd.

______________________________________________________________

3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary)

###-##-####

 

Evans FORM 5 (Continued)

 

__________________________________________________________

4. Statement for Month/Year

January, 2003

__________________________________________________________

5. If Amendment, Date of Original (Month/Year)

N/A

__________________________________________________________

6. Relationship of Reporting Person(s) to Issuer

(Check all applicable)

|X| Director |_10% Owner

|_ | Officer (give title below) |_ | Other (specify below)

_________________________________________________________

7. Individual or Joint/Group Filing

(check applicable line)

|X| Form filed by One Reporting Person

|_| Form filed by More than One Reporting Person

_________________________________________________________

 

 

 

 

 

 

Evans FORM 5 (Continued)

==================================================

Table I -- Non-Derivative Securities Acquired, Disposed of,

or Beneficially Owned

1. Title of Security

(Instr. 3)

2. Trans-

action

Date

 

 

(Month/

Day/

Year)

2A.

Deemed

Execution

Date, if

any

(Month/

Day

Year)

3. Trans-

action

Code

(Instr. 8)

4. Securities

Acquired (A)

or Disposed

of (D)

(Instr. 3,4 and 5)
     

 

Code

 

V

 

Amount

(A)

or

(D)

 

Price

Common Stock

    

 

 
           

 
               
               
               
               

5. Amount of

Securities

Beneficially

Owned

At the End of Issuer's

Fiscal Year

(Instr. 3 and 4)

6. Ownership

Form:

Direct (D) or

Indirect (I)

(Instr. 4)

 

 

7. Nature of

Indirect

Beneficial

Ownership

(Instr. 4)

660,000

D

 

   

===============================================

* If the form is filed by more than one reporting person, see instruction

4(b)(v).

PERSONS WHO 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.

(OVER)

SEC 2270 (9-02)

 

 

 

 

Evans 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

(Instr. 3)

2. Conver-

sion or

Exercise

Price of

Derivative

Security

3. Trans-

action

Date

(Month/

Day/Year)

3A. Deemed

Execution

Date, if

Any

(Month/

Day/Year)

4. Trans-

action

Code

(Instr. 8)
       

Code

V
           
           

5. Number of Deriv-

ative Securities

Acquired (A) or

Disposed of (D)

(Instr. 3,4 and 5)

6. Date Exer-

cisable and

Expiration

Date

(Month/Day

Year)

7. Title and

Amount of

Underlying

Securities

(Instr. 3 and 4)

8. Price

of Derivative Security (Instr. 5)

(A)

(D)

Date

Exer-

cisable

Expira-

tion

Date

Title

Amount

or Number

of Shares

  
             
             

 

9. Number of

derivative

Securities

Beneficially

Owned

at End of

Fiscal Year

(Instr. 4)

10. Ownership

Form of

Derivative

Security:

Direct (D)

or

Indirect (I)

(Instr. 4)

11. Nature of

Indirect

Beneficial

Ownership

(Instr. 4)

 
     
     
     

 

 

 

 

 

 

 

 

 

 

Evans FORM 5 (Continued)

- ----------------------------------------------------------------------------------------------------------------

Explanation of Responses:

/s/ Richard W. Evans February 5, 2003

- --------------------------------------------- -----------------------

Richard W. Evans

**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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evans FORM 5 02-2003