-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, LtEsMvnpjRpyu1vDJKkHqssBVscP0+WIZOkv4bz/hpURXTT9n758tXAiqnEaolC3 Qv7O0ztXDH2y4+A5Y/te/g== 0000950147-03-000046.txt : 20030121 0000950147-03-000046.hdr.sgml : 20030120 20030121124101 ACCESSION NUMBER: 0000950147-03-000046 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030101 FILED AS OF DATE: 20030121 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: H E R C PRODUCTS INC CENTRAL INDEX KEY: 0000919010 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MISCELLANEOUS REPAIR SERVICES [7600] IRS NUMBER: 860570800 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-13012 FILM NUMBER: 03519065 BUSINESS ADDRESS: STREET 1: 2202 W LONE CACTUS DR # 15 CITY: PHOENIX STATE: AZ ZIP: 85027-2621 BUSINESS PHONE: 6024920336 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: AFFHOLDER ROBERT W CENTRAL INDEX KEY: 0000946109 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: C/O INSITUFORM TECHNOLOGIES INC STREET 2: 702 SPIRIT 40 PARK DRIVE CITY: CHESTERFIELD STATE: MO ZIP: 63005 BUSINESS PHONE: 6365308000 4 1 e-9432.txt FORM 4 FOR ROBERT AFFHOLDER ------------------------------ OMB APPROVAL ------------------------------ - ------ OMB Number: 3235-0287 FORM 4 Expires: January 31, 2005 - ------ Estimated average burden hours per response ....... 0.5 ------------------------------ UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 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(h) of the Investment Company Act of 1940 [ ] Check this box if no longer subject of Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). ================================================================================ 1. Name and Address of Reporting Person* Affolder, Robert - -------------------------------------------------------------------------------- (Last) (First) (Middle) c/o H.E.R.C. Products Incorporated 1420 Columbus Avenue - -------------------------------------------------------------------------------- (Street) Portsmouth, Virginia 23704 - -------------------------------------------------------------------------------- (City) (State) (Zip) ================================================================================ 2. Issuer Name AND Ticker or Trading Symbol H.E.R.C. Products Incorporated (HERC) ================================================================================ 3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary) ================================================================================ 4. Statement for Month/Day/Year January 1, 2003 ================================================================================ 5. If Amendment, Date of Original (Month/Day/Year) ================================================================================ 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 ================================================================================ Page 1 of 3 Form 4 (continued) Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
========================================================================================================================== | | | | | 5. | | | | | | | Amount | | | | | | | of | | | | | | | Secur- | | | | | | 4. | ities | | 7. | | | | Securities | Bene- | 6. | Nature | | | | Acquired (A) | ficially | Owner- | of | | | | or Disposed | Owned | ship | Indirect | | 2A. | 3. | of (D) (Instr. | Following| Form: | Bene- | | Deemed | Transaction | 3, 4 and 5) | Reported | Direct | ficial | 2. | Execution | Code | ---------------- | Trans- | (D) or | Owner- 1. | Transaction | Date, if | (Instr. 8) | |(A)| | action(s)| Indirect | ship Title of Security | Date (Month/| any (Month/| ----------- | Amount|or |Price | (Instr. | (I) | (Instr. (Instr. 3) | Day/Year) | Day/Year) | Code | V | |(D)| | 3 and 4) | (Instr.4)| 4) - -------------------------------------------------------------------------------------------------------------------------- Common Stock 01/01/03 A(1) 25,000 A $.08 161,280 D - -------------------------------------------------------------------------------------------------------------------------- - -------------------------------------------------------------------------------------------------------------------------- - -------------------------------------------------------------------------------------------------------------------------- - -------------------------------------------------------------------------------------------------------------------------- ==========================================================================================================================
Page 2 of 3 Form 4 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
========================================================================================================================= | | | | |5. | | | |9. |10. | | | | | |Number | | | |Number |Owner-| | | | | |of | |7. | |of |ship | |2. | | | |Deriv- | |Title and | |Deriv- |of | |Conver-| | | |ative | |Amount of | |ative |Deriv-|11. |sion | | | |Secur- | |Underlying | |Secur- |ative |Nature |of | |3A. | |ities |6. |Securities |8. |ities |Secur-|of |Exer- | |Deemed |4. |Acquired |Date |(Instr. 3 |Price |Bene- |ity: |In- |cise |3. |Execu- |Trans- |(A) or |Exercisable and |and 4) |of |ficially|Direct|direct |Price |Trans- |tion |action |Disposed |Expiration Date |-------------|Deriv- |Owned |(D) or|Bene- 1. |of |action |Date, |Code |of(D) |(Month/Day/Year) | |Amount|ative |at End |In- |ficial Title of |Deriv- |Date |if any |(Instr.|(Instr.3,|-----------------| |or |Secur- |of |direct|Owner- Derivative |ative |(Month/ |(Month/ |8) |4 and 5) |Date | Expira-| |Number|ity |Month |(I) |ship Security |Secur- |Day/ |Day/ |------ |-------- |Exer- | tion | |of |(Instr.|(Instr. |(Instr|(Instr. (Instr. 3) |ity |Year) |Year) |Code|V |(A) | (D)|cisable | Date |Title |Shares|5) |4) |4) |4) - ------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------- =========================================================================================================================
Explanation of Responses: (1) The shares were issued to the reporting person and represents the reporting person's retainer fee. /s/ Robert Affholder 01/20/2003 - ------------------------------- ------------ **Signature of Reporting Person Date * If the form is filed by more than one reporting person, see Instruction 4(b)(v). ** 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 procedures. Page 3 of 3 -----END PRIVACY-ENHANCED MESSAGE-----