424010_1 UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
SCHEDULE 13G
Under the Securities Exchange Act of 1934
SURREY, INC.
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(Name of Issuer)
COMMON STOCK AND
REDEEMABLE COMMON STOCK PURCHASE WARRANTS
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(Title of Class of Securities)
Unit: CUSIP 86888L 20 8
Common Stock: CUSIP 86888L 10 9
Warrant: CUSIP 86888L 11 7
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(CUSIP Number)
JOHN VAN DER HAGEN
13110 TRAILS END ROAD
LEANDER, TX 78641
(512) 267-7272
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(Name, Address and Telephone Number of Person Authorized
to Receive Notices and Communications)
DECEMBER 31, 1997
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(Date of Event Which Requires Filing
of This Statement)
(Cover page continued on next page)
Page 1 of 5 Pages
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SCHEDULE 13G
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CUSIP NO. 86888L 20 8 PAGE 2 OF 5 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
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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
1,124,727 shares
SHARES
BENEFICIALLY
OWNED BY
EACH
REPORTING
PERSON
WITH
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6 SHARED VOTING POWER
-0- shares
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7 SOLE DISPOSITIVE POWER
1,124,727 (see item 4) shares
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8 SHARED DISPOSITIVE POWER
-0- shares
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9 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON
1,125,727 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)
47.4%
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12 TYPE OF REPORTING PERSON*
CO
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*SEE INSTRUCTIONS BEFORE FILLING OUT!
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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
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 and
Redeemable Common Stock Purchase Warrants
ITEM 2(e). CUSIP NO.
Unit: CUSIP 86888L 20 8
Common Stock: CUSIP 86888L 10 9
Warrant: CUSIP 86888L 11 7
Page 3 of 5 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.
(a) Amount Beneficially Owned: 1,125,727 shares
(includes 1,000 shares issuable pursuant to
1,000 redeemable common stock purchase warrants)
(b) Percent of Class (based on 2,373,727 shares outstanding,
including 1,000 shares issuable upon exercise of
Mr. van der Hagen's warrants)(1): 47.4%
(c) Number of shares as to which such person has:
(i) Sole power to vote or
to direct the vote (excluding
warrant shares): 1,124,727 shares
(ii) Shared power to vote or
to direct the vote: -0- shares
(iii) Sole power to dispose or
to direct the disposition of (pledged
to secure the Company's bank loan;
excluding warrant shares): 1,124,727 shares
(iv) Shared power to dispose or
to direct the disposition of: -0- shares
Page 4 of 5 Pages
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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.
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: January 7, 1998.
By: /s/ John B. van der Hagen
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John B. van der Hagen
Title: CEO
Page 5 of 5 Pages
