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OMB APPROVAL
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OMB Number 3235-0362
Expires: December 31, 2001
Estimated average burden
hours per response ....... 1.0
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U.S. 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 box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
[X] Form 3 Holdings Reported simultaneously with this Form 5
[_] Form 4 Transactions Reported
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1. Name and Address of Reporting Person*
LIGHT Dennis
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(Last) (First) (Middle)
7504 Diplomat Drive, Suite 101
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(Street)
Manassas Virginia 20109
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(City) (State) (Zip)
MID-ATLANTIC HOME HEALTH NETWORK, INC. "MAHN"
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2. Issuer Name and Ticker or Trading Symbol
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
February 15, 2000
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4. Statement for Month/Year
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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)
President
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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 Acquired, Disposed of,
or Beneficially Owned
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<CAPTION>
5. 6.
4. Amount of Owner-
Securities Acquired (A) or Securities ship
Disposed of (D) Beneficially Form: 7.
(Instr. 3, 4 and 5) Owned at End Direct Nature of
2. 3. ----------------------------- of Issuer's (D) or Indirect
1. Transaction Transaction (A) Fiscal Year Indirect Beneficial
Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C>
Common Stock None 216,000* D & I *Of this amount,
2,600 shares are
owned by Creative
Health Ventures
Inc., a company
owned and controlled
by Mr. Light; 1,400
shares are
registered in the
name of Nevada
Agency and Trust
Company as agent for
the Company's
Employee Stock
Purchase Plan: and
6,000 shares are
registered in the
name of Michael
Light, Mr. Light's
son.
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* 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.
(Over)
SEC 2270 (3-99)
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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
or 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>
None
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</TABLE>
Explanation of Responses:
/S/ Dennis Light June 9, 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.
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