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FORM 5
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/ / Check box if no U.S. SECURITIES AND EXCHANGE COMMISSION
longer subject to WASHINGTON, DC 20549 ---------------------------
Section 16. Form OMB APPROVAL
4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP ---------------------------
obligations may OMB Number: 3235-0362
continue. See Filed pursuant to Section 16(a) of the Securities Expires: April 30, 1997
Instruction 1(b) Exchange Act of 1934, Estimated average burden
/ / Form 3 Holdings Section 17(a) of the Public Utility hours per response......1.0
Reported Holding Company Act of 1935 or Section 30(f) of ---------------------------
/ / Form 4 the Investment Company Act
Transactions of 1940
Reported
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1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person to
Nichelson Donald E. Carey Diversified LLC "CDC" Issuer (Check all applicable)
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(Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- ---
Number of Reporting Month/Year Officer (give Other (Specify
124 West Channel Lane Person (Voluntary) 12/31/98 ---- title --- below)
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(Street) 5. If Amendment,
Date of Original
Haiey ID 83333 (Month/Year) 7. Individual of Joint/Group Filing
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(City) (State) (ZIP) -------------------
-- Form Filed by One Reporting Person
-- Form Filed by more than 1 Reporting
Person
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TABLE 1 -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature
(Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In-
Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct
(Instr. 8) End of Issuer's Direct Benefi-
(Month/ Fiscal Year (D) or cial
Day/ ---------------------------- (Instr. 3 and 4) Indirect Owner-
Year) Amount (A) or Price (I) ship
(D) (Instr. 4) (Instr.
4)
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Listed Shares 6/29/98 A 388 A D
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Listed Shares 9/29/98 A 386 A 9595 D
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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)
(Print or Type Responses)
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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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1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price
Security sion or action action Derivative cisable and of Underlying of
(Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv-
Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative
Deriv- Day/ Disposed of (D) (Month/Day/ Secur-
ative Year) (Instr. 3, 4, Year) ity
Security and 5) (Instr. 5)
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Date Expira- Amount or
--------------- Exer- tion Title Number of
(A) (D) cisable Date Shares
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Options $20 A 3,846 1 1/21/08 Listed 3,846 $20
Shares
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1. Title of Derivative 9. Number of 10. Ownership 11. Nature of
Security Derivative of Derivative Indirect
(Instr. 3) Securities Security: Beneficial
Beneficially Direct (D) Ownership
Owned at End or Indirect (I) (Instr. 4)
of Year (Instr. 4)
(Instr. 4)
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Options 7,846 D
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Explanation of Responses:
(1) The option vests in three equal installments beginning on January 21, 1999.
**Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ Donald Nichelson 2/10/99
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------------- -------
**Signature of Reporting Person Date
Note. File three copies of this Form, one of which must be manually signed. Page 2
If space provided is insufficient, see Instruction 6 for procedure.
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