UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
SCHEDULE 13G
Under the Securities Exchange Act of 1934
(Amendment No. 1)
SURREY, INC.
(Name of Issuer)
COMMON STOCK AND
REDEEMABLE COMMON STOCK PURCHASE WARRANTS
(Title of Class of Securities)
Unit: 86888L 20 8
Common Stock: 86888L 10 9
Warrant: 86888L 11 7
(CUSIP Number)
JOHN VAN DER HAGEN
13110 TRAILS END ROAD
LEANDER, TX 78641
(512) 267-7272
(Name, Address and Telephone Number of Person Authorized
to Receive Notices and Communications)
FEBRUARY 9, 1998
(Date of Event Which Requires Filing
of This Statement)
(Cover page continued on next page)
Page 1 of 6 Pages
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SCHEDULE 13G
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CUSIP NO. 86888L 10 9 PAGE 2 OF 6 PAGES
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1 NAMES OF REPORTING PERSON
S.S. OR I.R.S. IDENTIFICATION NOS. OF ABOVE PERSON
John B. van der Hagen and
Mary A. van der Hagen, joint tenants
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2 CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP* (a)|_|
(b)|_|
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3 SEC USE ONLY
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4 CITIZENSHIP OR PLACE OF ORGANIZATION
United States of America
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5 SOLE VOTING POWER
NUMBER OF 884,727 shares (see item 4)
SHARES ------------ --------------------------------------
BENEFICIALLY 6 SHARED VOTING POWER
OWNED BY
EACH -0- shares
REPORTING ------------ --------------------------------------
PERSON 7 SOLE DISPOSITIVE POWER
WITH
884,727 shares (see item 4)
------------ --------------------------------------
8 SHARED DISPOSITIVE POWER
-0- shares
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9 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON
885,727 shares (see item 4)
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10 CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN
SHARES* |_|
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11 PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (9)
35.8%
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12 TYPE OF REPORTING PERSON*
IN
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*SEE INSTRUCTIONS BEFORE FILLING OUT!
Page 2 of 6 Pages
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ITEM 1(a). NAME OF ISSUER.
Surrey, Inc.
ITEM 1(b). ADDRESS OF ISSUER'S PRINCIPAL EXECUTIVE OFFICES.
13110 Trails End Road
Leander, Tx 78641
ITEM 2(a). NAME OF PERSON FILING.
John B. van der Hagen And Mary A. van der Hagen,
Joint Tenants
ITEM 2(b). ADDRESS OF PRINCIPAL BUSINESS OFFICE OR, IF NONE, RESIDENCE.
13110 Trails End Road
Leander, Tx 78641
ITEM 2(c). CITIZENSHIP.
U.S.A.
ITEM 2(d). TITLE OF CLASS OF SECURITIES.
Common Stock, No Par Value, and
Redeemable Common Stock Purchase Warrants
ITEM 2(e). CUSIP NO.
Common Stock: CUSIP 86888L 10 9
Warrant: CUSIP 86888L 11 7
Page 3 of 6 Pages
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ITEM 3. IF THIS STATEMENT IS FILED PURSUANT TO RULES 13d-1(b), OR 13d-2(b),
CHECK WHETHER THE PERSON IS A:
[ ] (a) Broker or Dealer registered under Section 15 of the Act;
[ ] (b) Bank as defined in Section 3(a)(6) of the Act;
[ ] (c) Insurance Company as defined in Section 3(a)(19) of the Act;
[ ] (d) Investment Company registered under Section 8 of the
Investment Company Act;
[ ] (e) Investment Adviser registered under Section 203 of the
Investment Advisers Act of 1940;
[ ] (f) Employee Benefit Plan, Pension Fund which is subject to the
provisions of the Employee Retirement Income Security Act of
1974 or Endowment Fund; see Rule 13d-1(b)(1)(ii)(F);
[ ] (g) Parent Holding Company, in accordance with Rule
13d-1(b)(ii)(G) (Note: See Item 7); or
[ ] (h) Group, in accordance with Rule 13d-1(b)(1)(ii)(H).
Not Applicable.
ITEM 4. OWNERSHIP.
The Reporting Person transferred 240,000 shares by gift to members of
his immediate family.
(a) Amount Beneficially Owned by Reporting Persons as Joint Tenants:
885,727 shares
(includes 884,727 shares and 1,000 shares issuable pursuant to 1,000
redeemable common stock purchase warrants ("Warrants") which are
currently exercisable) (excludes 50,000 options to purchase shares
issuable under stock option plan which are not currently exercisable)
(b) Percent of Class (based on 2,473,727 shares outstanding), including
2,472,727 shares outstanding and 1,000 shares issuable upon exercise of
Mr. van der Hagen's Warrants): 35.8%
(c) Number of shares as to which such person has:
(i) Sole power to vote or to direct the vote (excluding warrant
shares): 884,727 shares
(ii) Shared power to vote or to direct the vote: -0- shares
Page 4 of 6 Pages
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(iii) Sole power to dispose or to direct the
disposition of: 884,727 shares
(iv) Shared power to dispose or to direct the
disposition of: -0- shares
ITEM 5. OWNERSHIP OF FIVE PERCENT OR LESS OF A CLASS.
Not applicable.
ITEM 6. OWNERSHIP OF MORE THAN FIVE PERCENT ON BEHALF OF ANOTHER PERSON.
Not applicable.
ITEM 7. IDENTIFICATION AND CLASSIFICATION OF THE SUBSIDIARY WHICH ACQUIRED THE
SECURITY BEING REPORTED ON BY THE PARENT HOLDING COMPANY.
Not applicable.
ITEM 8. IDENTIFICATION AND CLASSIFICATION OF MEMBERS OF THE GROUP.
Not applicable.
ITEM 9. NOTICE OF DISSOLUTION OF GROUP.
Not applicable.
ITEM 10. CERTIFICATION.
Not applicable.
Page 5 of 6 Pages
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SIGNATURE
After reasonable inquiry and to the best of my knowledge and belief, I
certify that the information set forth in this statement is true, complete and
correct.
Dated: February 17, 1998.
/s/ John B. van der Hagen
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John B. van der Hagen
/s/ Mary A. van der Hagen
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Mary A. van der Hagen
Page 6 of 6 Pages
