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FORM 5 UNITED STATES SECURITIES AND EXCHANGE COMMISSION OMB Approval
- ------------------------- Washington, D.C. 20549 ------------------------------
[ ] Check this box if no OMB Number: 3235-0362
longer subject to Expires: December 31, 2001
Section 16. Form 4 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Estimated average burden
or Form 5 obligations hours per response.......1.0
may continue. See ------------------------------
Instruction 1(b). Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934,
[ ] Form 3 Holdings Section 17(a) of the Public Utility Holding Company Act of 1935 or
Reported Section 30(f) of the Investment Company Act of 1940
[ ] Form 4 Transactions
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(s)
to Issuer (Check all applicable)
Lodgian, Inc. LOD
Leven Michael A. [X] Director [ ] 10% Owner
- ---------------------------------------------------------------------------------------- [ ] Officer (give [ ] Other (specify
(Last) (First) (Middle) 3. IRS or Social 4. Statement for title below)
Security Number of Month/Year below)
Reporting Person
c/o Lodgian, Inc. (Voluntary) 12/99
3445 Peachtree Road, N.E., Suite 700 ------------------------------------
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(Street) 5. If Amendment, 7. Individual or Joint/Group Reporting
Date of Original (check applicable line)
(Month/Year) [X] Form Filed by One Reporting Person
[ ] Form Filed by More than One Reporting
Atlanta GA 30326 Person
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(City) (State) (Zip)
TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
<S> <C> <C> <C> <C> <C> <C>
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1. Title of Security 2. Trans- 3. Transaction 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature of
(Instr. 3) action Code (Instr. or Disposed of (D) Securities Form: Indirect
Date 8) (Instr. 3, 4 and 5) Beneficially Direct (D) Beneficial
(Month/ Owned at End or Indirect Ownership
Day/ of Issuer's (I) (Instr. 4)
Year) Fiscal Year (Instr. 4)
(Instr. 3
and 4)
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Amount (A) or (D) Price
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Common Stock, par value 1/1/99(1) A 1,231 A 4.875 10,724 D
$.01 per share
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Common Stock, par value 4/1/99(1) A 1,231 A 4.4375 10,724 D
$.01 per share
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Common Stock, par value 7/1/99(1) A 1,231 A 6.5625 10,724 D
$.01 per share
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Common Stock, par value 10/1/99(1) A 1,231 A 3.75 10,724 D
$.01 per share
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Common Stock, par value 12/21/98 3(2) 5,700 10,724 I (2)
$.01 per share
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* If the form is filed by more than one reporting person, see Instruction 4(b)(v).
Page 1 of 2
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)
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
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1. Title 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date 7. Title 8. Price 9. Number 10. Owner- 11. Nature of
of sion or action action Derivative Exer- and of of ship Indirect
Deri- Exercise Date Code Securities cisable Amount Deri- Deri- Form Beneficial
vative Price of (Instr. Acquired (A) and Expi- of vative vative of Deri- Ownership
Secu- Deri- (Month/ 8) or Disposed ration Under- Secu- Secu- vative (Instr. 4)
rity vative Day/ of (D) Date Lying rity rities Security:
(Instr. Security Year) (Instr. 3, (Month/ Securi- (Instr. Benefi- Direct
3) 4, and 5) Day/ ties 5) cially (D) or
Year) (Instr. Owned Indirect
3 and 4) at End (I)
of (Instr.
Year 4)
(Instr.
4)
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(A) (D) Date Expir- Title Amount
Exerci- ation or
sable Date Number
of
Shares
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Option to $6.50 6/25/99 A 5,000 6/25/99 6/25/09 Common 5,000 30,000 D
Purchase Stock
Common
Stock,
par value
$0.01/share
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Explanation of Responses:
(1) Date represents the date of grant by the issuer. The certificates for these shares were received December 17, 1999.
(2) Represents indirect ownership of 5,700 shares of the Issuer's Common Stock owned by the Reporting Person's spouse which should
have been reported on the Reporting Person's Initial Statement of Beneficial Ownership of Securities on Form 3, which was filed
on December 22, 1998, the date on which the Reporting Person's filing obligations began.
** 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 /s/ Michael A. Leven February 10, 2000
signed. If space is insufficient, see Instruction 6 for ------------------------------------ --------------------
procedure. ** Signature of Reporting Person Date
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 control number.
Page 2 of 2
SEC 2270 (3-99)
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