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- -------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION -----------------------------
FORM 3 WASHINGTON, D.C. 20549 OMB APPROVAL
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INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES OMB Number: 3235-0104
Expires: September 30, 1998
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Estimated average burden
Section 17(a) of the Public Utility Holding Company Act of 1935 or hours per response .... 0.5
(Print or Type Responses) Section 30(f) of the Investment Company Act of 1940 -----------------------------
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1. Name and Address of Reporting Person* 2. Date of Event Re- 4. Issuer Name AND Ticker or Trading Symbol
quiring Statement
Lewis Edwin H. (Month/Day/Year) Mossimo, Inc. MGX (NYSE)
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(Last) (First) (Middle) 11/30/98 5. Relationship of Reporting Person(s) 6. If Amendment, Date
----------------------- to Issuer (Check all applicable) of Original
3. IRS or Social Se- X Director X 10% Owner (Month/Day/Year)
curity Number of ---- ----
2450 White Road, 2nd Floor Reporting Person Officer (give Other (specify ---------------------
- ------------------------------------------------- (Voluntary) X title below) below) 7. Individual or
(Street) ---- ---- Joint/Group Filing
Chief Executive Officer (Check Applicable
and President Line)
--------------------------- Form filed by One
X Reporting Person
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Form filed by
More than One
Reporting Person
Irvine California 92614 ---
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(City) (State) (Zip) TABLE I -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
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1. Title of Security 2. Amount of Securities 3. Ownership 4. Nature of Indirect Beneficial
(Instr. 4) Beneficially Owned Form: Direct Ownership (Instr. 5)
(Instr. 4) (D) or Indirect
(I) (Instr. 5)
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
* If the form is filed by more than one reporting person, SEE Instruction 5(b)(v). SEC 1473 (7-97)
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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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1. Title of Derivative Security 2. Date Exer- 3. Title and Amount of Securities 4. Conver- 5. Owner- 6. Nature of Indirect
(Instr. 4) cisable and Underlying Derivative Security sion or ship Beneficial
Expiration (Instr. 4) Exercise Form of Ownership
Date Price of Deriv- (Instr. 5)
(Month/Day/ Deri- ative
Year) vative Security:
-------------------------------------------------- Security Direct
Amount (D) or
Date Expir- or Indirect
Exer- ation Title Number of (I)
cisable Date Shares (Instr. 5)
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Nonqualified Stock Option 11/30/ 11/30/ Common Stock 5,152,778 $3.00 D
1998 2018
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Incentive Stock Option 11/30/ 11/30/ Common Stock 33,333 $3.00 D
1998 2008
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Nonqualified Performance Stock 11/30/ 11/30/ Common Stock 966,667 $3.00 D
Option 2005(1) 2018
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Performance Incentive Stock 11/30/ 11/30/ Common Stock 33,333 $3.00 D
Option 2005(1) 2008
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Explanation of Responses:
(1) Subject to accelerated vesting upon the happening of certain events relating in part to the Issuer's stock price.
/s/ EDWIN H. LEWIS 12/9/98
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**Intentional misstatements or omissions of facts constitute Federal **Signature of Reporting Person Date
Criminal Violations. SEE 18 U.S.C. 1001 and 15 U.S.C. 78f(a).
Note: File three copies of this Form, one of which must be manually signed. If space 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. Page 2
SEC 1473 (7-97)
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