3 1 e-5987.txt FORM 3 FOR MICHAEL C. PASCUCCI ------------------------------ OMB APPROVAL ------------------------------ ------ OMB Number 3235-0104 FORM 3 Expires: December 31, 2001 ------ Estimated average burden hours per response ....... 0.5 ------------------------------ U.S. SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 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 Pascucci Michael C -------------------------------------------------------------------------------- (Last) (First) (Middle) 270 South Service Road, Suite 45 -------------------------------------------------------------------------------- (Street) Melville New York 11747-2339 -------------------------------------------------------------------------------- (City) (State) (Zip) ================================================================================ 2. Date of Event Requiring Statement (Month/Day/Year) November 23, 1999 ================================================================================ 3. IRS or Social Security Number of Reporting Person (Voluntary) ================================================================================ 4. Issuer Name and Ticker or Trading Symbol Frontier Adjusters of America, Inc. (FAJ) ================================================================================ 5. Relationship of Reporting Person to Issuer (Check all applicable) [ ] Director [X] 10% Owner (1) [ ] Officer (give title below) [ ] Other (specify below) ---------------------------------- ================================================================================ 6. If Amendment, Date of Original (Month/Year) ================================================================================ 7. Individual or Joint/Group Filing (Check Applicable Line) [X] Form filed by One Reporting Person [ ] Form filed by More than One Reporting Person ================================================================================ FORM 3 (continued) Table I -- Non-Derivative Securities Beneficially Owned ================================================================================ 3. Ownership Form: 1. Title of 2. Amount of Securities Direct (D) or 4. Nature of Indirect Security Beneficially Owned Indirect (I) Beneficial Ownership (Instr. 4) (Instr. 4) (Instr. 5) (Instr.5) -------------------------------------------------------------------------------- Common Stock None (2) -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- ================================================================================ Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
Table II -- Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) =================================================================================================== 3. Title and Amount 5.Owner- of Securities Underlying ship Derivative Security Form of 2. Date Exercisable (Instr. 4) Derivative and Expiration Date ------------------------ 4. Conver- Security: (Month/Day/Year) Amount sion or Direct 6. Nature of 1. Title of -------------------- or Exercise (D) or Indirect Derivative Date Expira- Number Price of Indirect Beneficial Security Exer- tion of Derivative (I) Ownership (Instr. 4) cisable Date Title Shares Security (Instr.5) (Instr. 5) --------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------- ===================================================================================================
Explanation of Responses: /s/ Michael C. Pascucci December 29, 2000 ------------------------------- ----------------- **Signature of Reporting Person Date (1) The Reporting Person may be deemed to share voting and dispositive power over the shares of Common Stock of the Issuer described in Item 4. The Reporting Person disclaims beneficial ownership of these securities and the filing of this Form 3 shall not be deemed an admission that the Reporting Person is a beneficial owner or has voting or dispositive power over such securities for any purposes under the Act. (2) Does not include 5,258,513 shares owned by United Financial Adjusting Company with regard to which the Reporting Person disclaims any beneficial interest. ** 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.