1 --------------------------- OMB APPROVAL --------------------------- - ------ OMB Number: 3236-0287 FORM 4 Expires: February 1, 1994 - ------ Estimated average burden hours per response .... 0.5 --------------------------- U.S. SECURITIES AND EXCHANGE COMMISSION WASHINGTON, DC 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP / / Check this box if no longer subject to Filed pursuant to Section 16(a) of the Securities Section 16. Form 4 Exchange Act of 1934, Section 17(a) of the or Form 5 obligations Public Utility Holding Company Act of 1935 may continue. See or Section 30(f) of the Investment Company Instruction 1(b). Act of 1940
- ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person to Clemens Peter A. HALSEY DRUG CO., INC. (HDG) Issuer (Check all applicable) - ------------------------------------------- -------------------------------------------- Director 10% Owner (Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- --- c/o Halsey Drug Co., Inc. Number of Reporting Month/Year X Officer (give Other (Specify 1827 Pacific Street Person (Voluntary) 3/98 ---- title --- below) - --------------------------------------------- ###-##-#### ------------------- below) (Street) -------------------- 5. If Amendment, Vice President and Brooklyn, New York 11233 Date of Original Chief Financial Officer - --------------------------------------------- (Month/Year) -------------------------------------- (City) (State) (Zip) 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. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature (Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In- Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct (Instr. 8) End of Month Direct Benefi- (Month/ (Instr. 3 and 4) (D) or cial Day/ --------------------------------------- Indirect Owner- Year) Code V Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over) (Print or Type Responses) SEC 1474 (3/91) 2
FORM 4 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price Security sion or action action Derivative cisable and of Underlying of (Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv- Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative Deriv- Day/ Disposed of (D) (Month/Day/ Secur- ative Year) (Instr. 3, 4, Year) ity Security and 5) (Instr. 5) ----------------------------------- Date Expira- Amount or -------------------------- Exer- tion Title Number of Code V (A) (D) cisable Date Shares - ------------------------------------------------------------------------------------------------------------------------------------ Convertible Debenture 3/10/98 A * 3/10/98 3/10/03 Common Stock 66,667 - ------------------------------------------------------------------------------------------------------------------------------------ Stock Purchase Warrants 3/10/98 A * 3/10/98 3/10/05 Common Stock 10,101 - ------------------------------------------------------------------------------------------------------------------------------------ Stock Purchase Warrants 3/10/98 A * 3/10/98 3/10/05 Common Stock 10,101 - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative 9. Number of 10. Ownership 11. Nature of Security Derivative Form of Indirect (Instr. 3) Securities Derivative Beneficial Beneficially Security: Ownership Owned at End Direct (D) (Instr. 4) of Month or Indirect (I) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------- Convertible Debenture 66,667 Direct - ------------------------------------------------------------------------------------------------------- Stock Purchase Warrants 10,101 Direct - ------------------------------------------------------------------------------------------------------- Stock Purchase Warrants 10,101 Direct - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------- Explanation of Responses: * Purchased in connection with a private offering on March 10, 1998 consisting of a Convertible Debenture convertible at any time and Stock Purchase Warrants (10,101 shares of which are presently exercisable at $1.50 per share and 10,101 shares of which are presently exercisable at $2.38 per share). ** Intentional misstatements or omission of facts constitute Federal Criminal by: /s/ Peter A. Clemens 4/7/98 Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------------- ------ *Signature of Reporting Person Date Note. File three copies of this Form, one of which must be manually signed. Page 2 If space provided is insufficient, see Instruction 6 for procedure. SEC 1474 (3/91)