5 1 0001.txt FORM 5 UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 5 OMB APPROVAL ----------------------------- [_] Check box if no longer OMB NUMBER: 3235-0362 subject to Section 16. Form 4 Expires: December 31, 2001 or Form 5 obligations may Estimated average burden continue. See Instruction 1(b). hours per response ...... 1.0 ----------------------------- [_] Form 3 Holdings Reported [_] Form 4 Transaction Reported 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 1. Name and Address of Reporting Person* Scully Thomas -------------------------------------------------------------------------------- (Last) (First) (Middle) 21250 Hawthorne Blvd. #800 -------------------------------------------------------------------------------- (Street) Torrance CA 90503 -------------------------------------------------------------------------------- (City) (State) (Zip) -------------------------------------------------------------------------------- 2. Issuer Name and Ticker or Trading Symbol DVA -------------------------------------------------------------------------------- 3. IRS Identification Number of Reporting Person (Voluntary) -------------------------------------------------------------------------------- 4. Statement for Month/Year 12/31/2000 -------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Day/Year) -------------------------------------------------------------------------------- 6. Relationship of Reporting Person to Issuer (Check all applicable) X Director 10% Owner ----- ------ Officer (give Other (Specify ----- title below) ------ 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 1 -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned 1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature (Instr. 3) action action or Disposed of (D) Securities Form: of Indirect Date Code Beneficially Direct Beneficial (Instr. 8) (Instr. 3,4 and 5) Owned at End (D) or Ownership (Month/ -------------------------- Of Issuer's Indirect (Instr. 4) Day/ Amount (A) or Price Fiscal Year (I) Year) (D) (Instr. 3 and 4) (Instr. 4) -------------------------- ---------- ------ ---- -------- ------ ------ ---------------- ------------ ------------- -------------------------- ---------- ------ ---- -------- ------ ------ -------------- ------------ ------------- -------------------------- ---------- ------ ---- -------- ------ ------ -------------- ------------ ------------- -------------------------- ---------- ------ ---- -------- ------ ------ -------------- ------------ ------------- -------------------------- ---------- ------ ---- -------- ------ ------ -------------- ------------ ------------- -------------------------- ---------- ------ ---- -------- ------ ------ -------------- ------------ ------------- -------------------------- ---------- ------ ---- -------- ------ ------ -------------- ------------ ------------- -------------------------- ---------- ------ ---- -------- ------ ------ -------------- ------------ ------------- -------------------------- ---------- ------ ---- -------- ------ ------ -------------- ------------ ------------- -------------------------- ---------- ------ ---- -------- ------ ------ -------------- ------------ ------------- -------------------------- ---------- ------ ---- -------- ------ ------ -------------- ------------ ------------- *If form is by filed by more than one reporting person, see instruction 4(b)(v). 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 currently valid OMB control number.
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Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) 1. Title of Derivative Security 2. Conversion 3. Transaction 4. Transaction 5. Number of Derivative 6. Date Exercisable (Instr. 3) or Exercise Date Code Securities Acquired (A) and Expiration Price of (Month/Day/ (Instr. 8) or Disposed of (D) Date Derivative Year) (Instr. 3, 4, and 5) (Month/Day/ Security Year) -------------------------- ------------------- (A) (D) Date Expiration Exer- Date cisable ------------------------------- -------------- -------------- -------- ----- --------------- ---------- ------------------- ------------------------------- -------------- -------------- -------- ----- --------------- ---------- ------------------- Options (16b-3 Plan) $8.3125 10/04/00 A 21,000 (1) 10/4/05 ------------------------------- -------------- -------------- -------- ----- --------------- ---------- ------------------- ------------------------------- -------------- -------------- -------- ----- --------------- ---------- ------------------- ------------------------------- -------------- -------------- -------- ----- --------------- ---------- ------------------- ------------------------------- -------------- -------------- -------- ----- --------------- ---------- ------------------- ------------------------------- -------------- -------------- -------- ----- --------------- ---------- ------------------- ------------------------------- -------------- -------------- -------- ----- --------------- ---------- ------------------- ------------------------------- -------------- -------------- -------- ----- --------------- ---------- -------------------
7. Title and Amount of 8. Price of Derivative 9. Number of Derivative 10. Ownership Forms of 11. Nature of the Underlying Securities Security (Instr. 5) Securities Beneficially Derivative Security Indirect Beneficial (Instr. 3 and 4) Owned at End of Year Direct (D) or Ownership (Instr. 4) (Instr. 4) Indirect (I) (Instr. 4) ------------------------ Title Amount or Number of Shares ------------------------ ---------------------- -------------------------- --------------------------- ------------------------ ------------------------ ---------------------- -------------------------- --------------------------- ------------------------ Common Stock 21,000 21,000 D ------------------------ ---------------------- -------------------------- --------------------------- ------------------------ ------------------------ ---------------------- -------------------------- --------------------------- ------------------------ ------------------------ ---------------------- -------------------------- --------------------------- ------------------------ ------------------------ ---------------------- -------------------------- --------------------------- ------------------------ ------------------------ ---------------------- -------------------------- --------------------------- ------------------------ ------------------------ ---------------------- -------------------------- --------------------------- ------------------------ ------------------------ ---------------------- -------------------------- --------------------------- ------------------------
Explanation of Responses: /s/ Thomas Scully February 14, 2001 _______________________________ _________________ **Signature of Reporting Person Date (1) The indicated option vests at 25% per year, such that 5,250 shares shall vest on each of the following dates: 10/4/01, 10/4/02, 10/4/03 and 10/4/04. **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 procedure. Page 2 of 2