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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*
TCW Private Equity Holdings Corp. (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)
[ ] Director [ X ] 10% Owner
[ ] Officer (give title below) [ ] Other (specify below)
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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.
<PAGE>
FORM 4 (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- 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) TCW Private Equity Holdings Corp. is a member of TCW/Latin America Partners
L.L.C., which acts as managing general partner to a limited partnership that
owns indirectly (through TCW/CCI Holding L.L.C.) Series C Preferred Stock. TCW
Private Equity Holdings Corp. is a wholly owned subsidiary of TCW Advisors Inc.,
which is in turn a wholly owned subsidiary of TCW Investment Management Company.
TCW Group Inc. is the holding company of TCW Investment Management Company;
Robert Day is Chairman of the Board and Chief Executive Officer and a
shareholder of TCW Group Inc.; amounts shown in columns 7 and 9 represent the
reporting persons' percentage of interest in Series C Preferred Shares owned by
TCW/CCI Holding L.L.C.
(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 Options became immediately exercisable upon termination of
the Hart-Scott-Rodino waiting period on November 16, 1999.
/s/ Susan Marsch 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)
<PAGE>
Joint Filer Information
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Name: TCW Advisors, Inc.**
Address: 200 Park Avenue, Suite 2100
New York, NY 10166
Designated Filer: TCW Private Equity Holdings Corp.
Issuer: Convergence Communications, Inc.
Date of Event Requiring Statement: 11/16/99
Signature /s/ Susan Marsch
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Authorized Signatory
** Disclaims beneficial ownership
Joint Filer Information
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Name: TCW Investment Management Company **
Address: 865 South Figueroa Street, Suite 1800
Los Angeles, California 90017
Designated Filer: TCW Private Equity Holdings Corp.
Issuer: Convergence Communications, Inc.
Date of Event Requiring Statement: 11/16/99
Signature /s/ Susan Marsch
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Authorized Signatory
**Disclaims beneficial ownership
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Joint Filer Information
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Name: The TCW Group, Inc.**
Address: 865 South Figueroa Street, Suite 1800
Los Angeles, California 90017
Designated Filer: TCW Private Equity Holdings Corp.
Issuer: Convergence Communications, Inc.
Date of Event Requiring Statement: 11/16/99
Signature /s/ Susan Marsch
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Authorized Signatory
**Disclaims beneficial ownership
Joint Filer Information
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Name: Robert A. Day**
Address: 200 Park Avenue, Suite 2100
New York, NY 10166
Designated Filer: TCW Private Equity Holdings Corp.
Issuer: Convergence Communications, Inc.
Date of Event Requiring Statement: 11/16/99
Signature /s/ Susan Marsch
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Under Power of Attorney, dated March 31,
1999, filed as Exhibit A hereto.
**Disclaims beneficial ownership
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Exhibit A
POWER OF ATTORNEY
The undersigned, Robert Day, does hereby appoint Michael E. Cahill,
Marie M. Bender and Susan Marsch, and each of them, acting singly, with full
power of substitution, as the true and lawful attorney of the undersigned, to
sign on its behalf, and to file filings and any amendments thereto made by or on
behalf of the undersigned in respect of the beneficial ownership of equity
pursuant to sections 13(d), 13(f), 13(g), 14(d) and 16(a) of the Securities and
Exchange Act of 1934, as amended.
IN WITNESS WHEREOF, this Power of Attorney has been executed as of the
31st day of March, 1999.
/s/ Robert Day
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ROBERT DAY
