5 1 form5_hschneider-dec01.txt FORM 5 ON BEHALF OF HENRY SCHNEIDER 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 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* Schneider Henry -------------------------------------------------------------------------------- (Last) (First) (Middle) One North Lexington Avenue - 4th Floor -------------------------------------------------------------------------------- (Street) White Plaines NY 10601 -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol U.S. Energy Systems, Inc. (USEY) ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year 12/01 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person to Issuer (Check all applicable) [X] Director [X] 10% Owner [X] Officer (give title below) [_] Other (specify below) Vice President ________________________________________________________________________________ 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) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Series A (1) 12/14/01 J(1) 861,110 Common 3,444,440 0 Preferred Stock Stock ------------------------------------------------------------------------------------------------------------------------------------ Series A (1) 12/14/01 J(1) 50,000 Common 200,000 0 Preferred Stock Stock ------------------------------------------------------------------------------------------------------------------------------------ Series D (1) 12/14/01 J(1) 861,110 Immed. Common 3,444,440 3,444,000 I (2) Preferred Stock Stock ------------------------------------------------------------------------------------------------------------------------------------ Series D (1) 12/14/01 J(1) 50,000 Immed. Common 200,000 50,000 D Preferred Stock Stock ------------------------------------------------------------------------------------------------------------------------------------ Series B Warrants $4.00 12/14/01 J(1) 702,641 Immed. 7/30/05 Common 702,641 702,641 I (2) Stock ------------------------------------------------------------------------------------------------------------------------------------ Series B Warrants $4.00 12/14/01 J(1) 65,854 Immed. 7/30/05 Common 65,854 65,854 D Stock ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock $4.563 (3) A 500,000 Immed. 9/07/10 Common 500,000 500,000 D Option (Right to Buy) Stock ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: (1) Pursuant to the Issuer's Plan of Recapitalization, all of the Issuer's outstanding shares of Series A Preferred Stock (the "Series A Stock") were exchanged for the Issuer's Series D Preferred Stock (the "Series D Stock") and Series B Warrants. The grants by the Issuer of the Series D Stock and the Series B Warrants and the acquisition by the Issuer of the Series A Stock were approved prior to their implementation by the board of directors and stockholders of the Issuer (and are exempt pursuant to, among other things, Rule 16b-3(d) and (e)) and were completed, after all conditions to the Plan had been satisfied, in December 2001. The purchase price for the 861,110 shares of the Series A Stock was reduced from $9.00 per share to approximately $8.60 per share pursuant to the Plan of Recapitalization. The conversion price of each series of preferred stock is $2.25 (subject to adjustment under certain circumstances) and each share of Series D Stock is currently convertible into four shares of common stock. (2) The securities reflected as owned indirectly are beneficially owned directly by Energy Systems Investors, LLC ("ESI"). ESI is managed by Energy Systems Investors II, LLC ("ESI II"). Henry Schneider is a member of ESI II and in such capacity shares the power to vote and direct the disposition of the U.S. Energy securities owned by ESI (the "Relationship"). Accordingly, ESI II and Henry Schneider may be deemed to beneficially own such shares indirectly. The extent to which Henry Schneider may have an indirect pecuniary interest in the U.S. Energy securities reported as owned by ESI and ESI II as a result of the Relationship is not currently determinable. Henry Schneider disclaims beneficial ownership of U.S. Energy securites reported herein as beneficially owned by him to the extent he does not have a pecuniary interest in such securities. (3) The Plan, pursuant to which this option was granted was adopted by the stockholders of U.S. Energy on April 2, 2001. /s/Henry Schneider August 7, 2002 --------------------------------------------- ----------------------- Henry Schneider 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. Page 2