4 1 form4pierce122502.txt FORM 4 FOR ANDREW PIERCE DATED 12/25/02
---------- FORM 4 ---------- ------------------------- [ ] Check this box if no longer OMB APPROVAL subject to Section 16. Form 4 ------------------------- or Form 5 obligations may OMB Number: 3235-0287 continue. See Instruction 1(b). Expires: January 31, 2005 Estimated average burden hours per response....0.5 ------------------------- U.S. SECURITIES AND EXCHANGE COMMISSION WASHINGTON, DC 20549 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 ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker Trading Symbol 6. Relationship of Reporting Person(s) to Issuer FX Energy, Inc. ("FXEN") (Check all applicable) Pierce, Andrew W. [X] Director [ ] 10% Owner ----------------------------------------------------------------------------------------------- [X] Officer(give [ ] Other (specify (Last) (First) (Middle) 3. IRS Identification 4.Statement for Month/Day/Year title below below) Number of Reporting Vice President and 3006 Highland Drive, Suite 206 Person, if an entity December 25, 2002 Chief Operations Officer ------------------------------------------ (voluntary) ---------------------------- ------------------------------------ (Street) 5. If Amendment, Date 7. Individual or Joint/Group Filing of Original (Check Applicable Line) (Month/Year) [X] Form filed by One Reporting Person [ ] Form filed by More than One Salt Lake City, UT 84106 Reporting Person ----------------------------------------------------------------------------------------------------------------------------------- (City) (State) (Zip) ----------------------------------------------------------------------------------------------------------------------------------- TABLE 1 -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ----------------------------------------------------------------------------------------------------------------------------------- 1. Title of Security 2. Trans- 2A. 3. Transaction 4. Securities Acquired(A) 5. Amount of 6.Owner- 7. Nature of (Instr. 3) action Deemed Code or Disposed of (D) Securities ship Indirect Date Execution (Instr.8) (Instr. 3,4 and 5) Beneficially Form: Beneficial Date, if -------------- ------------------------- Owned at End Direct (D) Ownership any of Month or Indirect (Month/ (Month/ (A) Day/ Day/ or Year) Year) Code V Amount (D) Price (Instr. 3 and 4) (I) (Instr.4) (Instr.4) ----------------------------------------------------------------------------------------------------------------------------------- Common Stock, 12/25/ 8,000 Par Value $0.001 02 G Note (A) D $2.59 57,103 D ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. * If the form is filed by more than one reporting person, see Instruction on 4(b)(v). Persons who respond to the collection of information contained (Over) in this form are not required to respond unless the form SEC 1474(9-02) displays a currently valid OMB control number.
FORM 4 (CONTINUED) Table II -- Derivative Securities Acquired, Disposed of, or Benficially Owned (e.g., puts, calls, warrants, options, convertible securities) ----------------------------------------------------------------------------------------------------------------------------------- 1.Title of 2.Conver- 3.Trans- 3A. 4.Tansac- 5.Number of 6.Date Exercis- 7.Title and 8.Price 9.Number 10.Owner- 11.Nature Derivative sion or action Deemed tion Derivative able and Amount of of of Deri- ship of In- Security Exercise Date Execution Code Securities Expiration Underlying Deri- vative Form of direct (Instr.3) Price of (Month/ Date, if (Instr.8) Acquired Date Securities vative Secur- Deriva- Bene- Deri- Day/ any (A) or (Month/Day/ (Intr. 3 Secu- ities tive ficial vative Year) (Month/ Disposed Year) and 4) rity Benefi- Security: Owner- Security Day/ of (D) --------------- ------------ (Instr. cially Direct ship Year) (Instr.3, Amount 5) Owned (D) or (Instr. 4 and 5) or at End Indirect 4) Date Expir- Title Number of (I) -------------------- Exer- ation of Month (Instr.4) Code V (A) (D) cisable Date Shares (Instr.4) ------------------------------------------------------------------------------------------------------------------------------------ Opton to Purchase 06/09/ Common Common Stock $3.00 Note(B) 04 Stock 500,000 500,000 D ------------------------------------------------------------------------------------------------------------------------------------ Opton to Purchase 11/05/96 11/05/ Common Common Stock $8.875 Note(C) 03 Stock 65,000 65,000 D ------------------------------------------------------------------------------------------------------------------------------------ Opton to Purchase 12/01/98 12/01/ Common Common Stock $6.625 Note(D) 04 Stock 45,000 45,000 D ------------------------------------------------------------------------------------------------------------------------------------ Opton to Purchase 11/10/99 11/10/ Common Common Stock $8.625 Note(D) 05 Stock 50,000 50,000 D ------------------------------------------------------------------------------------------------------------------------------------ Opton to Purchase 11/01/00 11/01/ Common Common Stock $5.75 Note(D) 06 Stock 50,000 50,000 D ------------------------------------------------------------------------------------------------------------------------------------ Opton to Purchase 10/18/01 10/18/ Common Common Stock $4.0625 Note(D) 07 Stock 50,000 50,000 D ------------------------------------------------------------------------------------------------------------------------------------ Opton to Purchase 11/12/02 11/12/ Common Common Stock $2.44 Note(D) 08 Stock 50,000 50,000 D ------------------------------------------------------------------------------------------------------------------------------------ Opton to 08/14/03 Purchase 08/14/ Notes 08/14/ Common Common Stock $2.40 02 A V 75,000 (D) & (E) 09 Stock 75,000 75,000 D ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: (A) The reporting person made a gift of the 8,000 in 1,000 shares increments to various non-insider individuals. (B) This option became exercisable in annual increments of 20%, commencing June 1, 1995. (C) This option vested 50% on grant and 50% on November 5, 1997. (D) Each of these options vests 1/3 on each anniversary of grant until fully vested. (E) The foregoing derivative detail is provided in advance of the Form 5 filing date. Form 5 would have been available to this reporting person as the transaction disclosed above occurred before the August 29, 2002, change in reporting deadlines pursuant to the Sarbanes-Oxley Act. This Form 4 is provided in lieu of any previously required Form 5. by: /s/ Andrew W. Pierce 12/26/02 -------------------------------- -------- 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. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a current valid OMB Number.