5 1 d27997_form-5.txt FORM 5 U.S. 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(f) of the Investment Company Act of 1940 [_] Check this 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* Thorn Tree Resources LLC -------------------------------------------------------------------------------- (Last) (First) (Middle) 888 Seventh Avenue, Suite 1608 -------------------------------------------------------------------------------- (Street) New York, New York 10106 -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol Emex Corporation (EMEX) ________________________________________________________________________________ 3. IRS or Social Security Number of Reporting Person (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year December 2001 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person to Issuer (Check all applicable) [_] Director [X] 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 ________________________________________________________________________________ ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================
5. 6. 4. Amount of Owner- Securities Acquired (A) or Securities ship Disposed of (D) Beneficially Form: 7. (Instr. 3, 4 and 5) Owned at End Direct Nature of 2. 3. ----------------------------- of Issuer's (D) or Indirect 1. Transaction Transaction (A) Fiscal Year Indirect Beneficial Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership (Instr. 3) (mm/dd/yy) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* If the form is filed by more than one Reporting Person, see Instruction 4(b)(v). Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Print or Type Responses) (Over) FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
9. 10. Number Owner- of ship 2. Deriv- of Conver- 5. 7. ative Deriv- 11. sion Number of Title and Amount Secur- ative Nature or Derivative 6. of Underlying 8. ities Secur- of Exer- Securities Date Securities Price Bene- ity: In- cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) ------------------------------------------------------------------------------------------------------------------------------------ Convertible Note $10.00 5/21/01 J(1) $225,000 Immed. --- Common 23,062 $225,000 $1,085,040 D (1) Stock ------------------------------------------------------------------------------------------------------------------------------------ Convertible Note $10.00 6/1/01 J(2) $860,040 Immed. --- Common 88,154 $860,040 $1,085,040 D (2) Stock ------------------------------------------------------------------------------------------------------------------------------------ Convertible Note $7.00 10/17/01 J(3) $6,000,000 Immed. --- Common 878,570 $6,000,000 $6,000,000 D (3) Stock ------------------------------------------------------------------------------------------------------------------------------------ Common Stock $7.00 10/17/01 J(4) 500,000 (4) Immed. 10/17/06 Common 512,500 $7.00 500,000 D Warrants (Right Stock to Buy) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: (1) Thorn Tree Resources LLC, a Delaware limited liability company ("Thorn Tree") loaned to Emex Corporation (the "Issuer") the principal amount of $225,000 in May 2001. The outstanding principal of the loan accrues interest at the rate of 7 percent per annum. The outstanding principal and interest are due on July 31, 2002. From and after May 21, 2001, Thorn Tree had the right to convert the outstanding principal and interest to the Issuer's Common Stock at $10.00 per share. The number of underlying shares in item 7 above represents the number of shares of the Issuer's Common Stock that Thorn Tree would receive upon conversion of the entire principal amount, as adjusted to reflect a 2.5% dividend declared by the Issuer on December 31, 2001. The number does not take into account shares that would be received upon conversion of accrued interest. (2) Thorn Tree loaned to the Issuer the principal amount of $860,040 in June 2001. The outstanding principal of the loan accrues interest at a rate of 7 percent per annum. The outstanding principal and interest are due on July 31, 2002. From and after June 1, 2001, Thorn Tree had the right to convert the outstanding principal and interest to the Issuer's Common Stock at $10.00 per share. The number of underlying shares in item 7 above represents the number of shares of the Issuer's Common Stock that Thorn Tree would receive upon conversion of the entire principal amount, as adjusted to reflect a 2.5% dividend declared by the Issuer on December 31, 2001. The number does not take into account shares that would be received upon conversion of accrued interest. (3) Thorn Tree loaned to the Issuer the principal amount of $6,000,000 in October 2001. The outstanding principal of the loan accrues interest at the rate of the Prime Rate at J.P. Morgan Chase & Co. as of October 17, 2001 plus three percent per annum. The outstanding principal and interest are due on December 31, 2002. From and after October 17, 2001, Thorn Tree had the right to cause the outstanding debt to be converted to the Issuer's Common Stock at $7.00 per share. The number of underlying shares in item 7 above represents the number of shares of the Issuer's Common Stock that Thorn Tree would receive upon conversion of the entire principal amount, as adjusted to reflect a 2.5% dividend declared by the Issuer on December 31, 2001. The number does not take into account shares that would be received upon conversion of accrued interest. (4) In consideration of the loan in the principal amount of $6,000,000, Thorn Tree was granted warrants to purchase 500,000 shares of the Issuer's Common Stock at $7.00 per share. The warrants are exercisable at any time and expire on October 17, 2006. The number of underlying shares in item 7 above represents the number of shares of the Issuer's Common Stock that Thorn Tree would receive upon exercise of the warrants, as adjusted to reflect a 2.5% dividend declared by the Issuer on December 31, 2001. /s/ David H. Peipers February 15, 2002 --------------------------------------------- ----------------------- **Signature of Reporting Person Date Name: David H. Peipers Title: Manager ** 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. SEC 2270 (7/96)