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OMB APPROVAL
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OMB Number 3235-0287
Expires: December 31, 2001
Estimated average burden
hours per response ....... 0.5
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 4
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 of Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
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1. Name and Address of Reporting Person*
Baeza Mario L. (1)
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(Last) (First) (Middle)
200 Park Avenue, Suite 2100
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(Street)
New York New York 10166
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Convergence Communications, Inc.
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
November, 99
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person to Issuer
(Check all applicable)
[ X ] Director [ X ] 10% Owner
[ ] Officer (give title below) [ ] Other (specify below)
Founder and Vice Chairman
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7. Individual or Joint/Group Filing (Check applicable line)
[ ] Form filed by one Reporting Person
[ X ] Form filed by more than one Reporting Person
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Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
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<TABLE>
<CAPTION>
6.
4. 5. Owner-
Securities Acquired (A) or Amount of ship
3. Disposed of (D) Securities Form: 7.
Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of
2. Code ------------------------------- Owned at End (D) or Indirect
1. Transaction (Instr. 8) (A) of Month Indirect Beneficial
Title of Security Date ------------ Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) Code V (D) and 4) (Instr.4) (Instr. 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
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</TABLE>
* If the Form is filed by more than one Reporting Person, see Instruction
4(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
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FORM 4 (continued)
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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- 4. Securities Date Securities Price Bene- ity: In-
cise 3. Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- action or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Code of(D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date (Instr. (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ 8) 4 and 5) Date Expira- Number ity Month (I) ship
Security Secur- Day/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) Code V (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> <C>
Series C 1-for-1 11/16/99 P 6,666.7 Immed. Common 6,666.7 $7.50 16,666.7 I (2)
Convertible Stock
Preferred Stock
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Option to purchase $7.50/ 11/16/99 P 6,666.7 Immed. 7/18/00 Series C 6,666.7 (3) 6,666.7 I (2)
shares of Series C Share Convertible
Convertible Preferred
Preferred Stock Stock
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</TABLE>
Explanation of Responses:
(1) Disclaims beneficial ownership
(2) Mario L. Baeza is an officer and sole member of Baeza & Co., a member of a
limited liability company which acts as managing general partner to a limited
partnership that owns indirectly (through TCW/CCI Holding L.L.C.) Series C
Preferred Stock; columns 7 and 9 amounts reflect the reporting persons' indirect
ownership of TCW/CCI Holding L.L.C.'s holdings based on the reporting persons'
interest in such general partner.
(3) In connection with the purchase of shares of Series C Convertible Preferred
Stock at $7.50 per share on October 18, 1999 and November 16, 1999, TCW/CCI
Holding L.L.C. was granted, for no additional consideration, an Option to
purchase an amount of additional shares of Series C Convertible Preferred Stock
equal to 40% of the total number of shares of Series C Convertible Preferred
Stock acquired. Such Option became immediately exercisable upon termination of
the Hart-Scott-Rodino waiting period on November 16, 1999.
/s/ Mario L. Baeza 12/10/99
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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 procedures.
Alternatively, this Form is permitted to be submitted to the
Commission in electronic format at the option of the reporting person
pursuant to ruke 101(b)(4) of Regulatiob S-T.
(122797DTI)
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Joint Filer Information
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Name: Baeza & Co., L.L.C.**
Address: 123 Hillside Avenue
Englewood, NJ 07631
Designated Filer: Mario L. Baeza
Issuer: Convergence Communications, Inc.
Date of Event Requiring Statement: 11/16/99
Signature /s/ Mario L. Baeza
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Authorized Signatory
**Disclaims beneficial ownership
