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OMB APPROVAL
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OMB Number 3235-0362
Expires: September 30, 1998
Estimated average burden
hours per response ....... 1.0
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 5
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
[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
[ ] Form 3 Holdings Reported
[ ] Form 4 Transactions Reported
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1. Name and Address of Reporting Person*
RAHN JONATHAN D.
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(Last) (First) (Middle)
413 GATEWOOD ROAD
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(Street)
CHERRY HILL, NJ 08003
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
PACIFIC HEALTH LABORATORIES, INC. (Nasdaq:PHLI)
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
FYE 12/31/99
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
[ X ] Director [ ] 10% Owner
[ X ] Officer (give title below) [ ] Other (specify below)
EXECUTIVE VP, CFO
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7. Individual or Joint/Group Reporting
(check applicable line)
X Form Filed by One Reporting Person
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Form Filed by More than One Reporting Person
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<PAGE>
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Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
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<TABLE>
<CAPTION>
5. 6.
2. 3. 4. Amount of Owner-
Transaction Transaction Securities Acquired (A) or Securities ship
Date Code Disposed of (D) Beneficially Form: 7.
(Month/ (Instr. 8) (Instr. 3, 4 and 5) Owned at End Direct Nature of
Day/ of Issuer's (D) or Indirect
1. Year) Fiscal Year Indirect Beneficial
Title of Security -------------------------- (Instr. 3 (I) Ownership
(Instr. 3) Amount (A)or Price and 4) (Instr. 4)(Instr. 4)
(D)
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<S> <C> <C> <C> <C> <C> <C> <C> <C>
Common Stock, par value $.0025 -- -- -- -- -- 243,000 D
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</TABLE>
*If the form is filed by more than one reporting person,
see instruction 4(b)(v).
<PAGE>
FORM 5 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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<TABLE>
<CAPTION>
9. 10.
Number Owner-
of ship
2. Deriv- of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
of Derivative 6. of Underlying 8. ities Secur- of
Exer- Securities Date Securities Price Bene- ity: In-
cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship
Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
6-30- Common
Option to buy -- -- -- -- -- Present 2001 Stock 200,000 -- 200,000 D --
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3-2- 3-2- Common
Option to buy -- -- -- -- -- 2000 2004 Stock 50,000 -- 50,000 D --
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</TABLE>
Explanation of Responses:
** Intentional misstatements or omissions of facts constitute Federal Criminal
Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
/s/ Jonathan D. Rahn February 10, 2000
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**Signature of Reporting Person Date
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 currently
valid OMB number.
