U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 3
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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
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1. Name and Address of Reporting Person*
David W. Niemiec
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(Last) (First) (Middle)
535 Madison Avenue
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(Street)
New York, NY 10022
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(City) (State) (Zip)
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2. Date of Event Requiring Statement (Month/Day/Year)
12/30/99
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Issuer Name and Ticker or Trading Symbol
Emeritus Corporation (AMEX: ESC)
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5. Relationship of Reporting Person to Issuer
(Check all applicable)
[X] Director [X] 10% Owner
[_] Officer (give title below) [_] Other (specify below)
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6. If Amendment, Date of Original (Month/Day/Year)
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7. Individual or Joint/Group Filing (Check applicable line)
[X] Form Filed by One Reporting Person
[_] Form Filed by More than One Reporting Person
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Table I -- Non-Derivative Securities Beneficially Owned
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<TABLE>
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3. Ownership Form:
2. Amount of Securities Direct (D) or
1. Title of Security Beneficially Owned Indirect (I) 4. Nature of Indirect Beneficial Ownership
(Instr. 4) (Instr. 4) (Instr. 5) (Instr. 4)
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<S> <C> <C> <C>
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* If the Form is filed by more than one Reporting Person, see Instruction
5(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Over)
(Form 3-07/99)
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FORM 3 (continued)
Table II -- Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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<TABLE>
<CAPTION>
5. Owner-
3. Title and Amount of Securities ship
Underlying Derivative Security Form of
2. Date Exercisable (Instr. 4) Derivative
and Expiration Date --------------------------------- 4. Conver- Security:
(Month/Day/Year) Amount sion or Direct 6. Nature of
---------------------- or Exercise (D) or Indirect
Date Expira- Number Price of Indirect Beneficial
1. Title of Derivative Exer- tion of Derivative (I) Ownership
Security (Instr. 4) cisable Date Title Shares Security (Instr. 5) (Instr. 5)
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<S> <C> <C> <C> <C> <C> <C> <C>
Series B Convertible 12/30/99 Common Stock, par 4,155,124 $7.22 per (I) See Note 1
Preferred Stock, par value $.0001 share Below
value $.0001, with a
stated value of $1,000
per share
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Explanation of Responses:
Note 1 - David W. Niemiec may deemed to have beneficial ownership of 30,000
shares of Series B Convertible Preferred Stock which upon conversion constitutes
4,155,124 shares of Common Stock through his position as Member of Saratoga
Management Company LLC which may be deemed to have indirect beneficial ownership
of such shares.
/s/ David W. Niemiec January 10, 2000
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**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 currently
valid OMB Number.
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