UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
SCHEDULE 13D
(AMENDMENT NO. 1)
UNDER THE SECURITIES EXCHANGE ACT OF 1934
SURREY, INC.
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(Name of Issuer)
COMMON STOCK
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(Title of Class of Securities)
86888L 10 9
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(CUSIP Number)
JOHN VAN DER HAGEN
SURREY, INC.
13110 TRAILS END ROAD
LEANDER, TEXAS 78641
(512) 267-7172
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(Name, Address and Telephone Number of Person
Authorized to Receive Notices and Communications)
DECEMBER 31, 1999
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(Date of Event Which Requires Filing of This Statement)
If the filing person has previously filed a statement on Schedule 13G
to report the acquisition which is the subject of this Schedule 13D, and is
filing this schedule because of Rule 13d-l(e), 13d-1(f) or 13d-1(g), check the
following box. |_|
The information required on the remainder of this cover page shall not
be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange
Act of 1934 ("Act") or otherwise subject to the liabilities of that section of
the Act but shall be subject to all other provisions of the Act.
(Cover page continued on next page)
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SCHEDULE 13D
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CUSIP NO. 86888L 10 9 PAGE 2 OF 4 PAGES
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1 NAME OF REPORTING PERSON
I.R.S. IDENTIFICATION NOS. OF ABOVE PERSON (ENTITIES ONLY)
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 SOURCE OF FUNDS*
N/A (See item 3)
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5 CHECK BOX IF DISCLOSURE OF LEGAL PROCEEDINGS IS REQUIRED PURSUANT TO
ITEMS 2(d) OR 2(e) |_|
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6 CITIZENSHIP OR PLACE OF ORGANIZATION
United States of America
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NUMBER OF 7 SOLE VOTING POWER
SHARES 920,727
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BENEFICIALLY 8 SHARED VOTING POWER
OWNED BY -0-
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EACH 9 SOLE DISPOSITIVE POWER
REPORTING 920,727
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PERSON 10 SHARED DISPOSITIVE POWER
WITH -0-
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11 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON
920,727
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12 CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (11) EXCLUDES CERTAIN
SHARES* |_|
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13 PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (11)
37.0%
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14 TYPE OF REPORTING PERSON*
IN
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*SEE INSTRUCTIONS BEFORE FILLING OUT!
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ITEM 1. SECURITY AND ISSUER.
This statement relates to Common Stock, no par value, of Surrey,
Inc. ("Issuer"), a Texas corporation, having its principal executive offices at
13110 Trails End Road, Leander, Texas 78641.
ITEM 2. IDENTITY AND BACKGROUND.
2(a) John B. van der Hagen and Mary A. van der Hagen,
joint tenants
2(b) 13110 Trails End Road, Leander, Texas 78641
2(c) Chief Executive Officer and Secretary, respectively,
of Surrey, Inc.
2(d) N/A
2(e) N/A
2(f) United States of America
ITEM 3. SOURCE AND AMOUNT OF FUNDS OR OTHER CONSIDERATION.
Mr. John van der Hagen acquired shares of the Issuer at its
inception using personal funds. Mrs. Mary van der Hagen became a joint tenant
for no additional contribution.
ITEM 4. PURPOSE OF TRANSACTION.
Mr. and Mrs. van der Hagen hold the shares in the Issuer for
investment purposes. Both Mr. and Mrs. van der Hagen intend to continue
holding such shares for investment purposes only as passive investors.
ITEM 5. INTEREST IN SECURITIES OF THE ISSUER.
Mr. and Mrs. van der Hagen own a total of 884,727 shares of common
stock of the Issuer, redeemable common stock purchase warrants to purchase 1,000
shares of the Issuer and currently exercisable options to purchase 35,500 shares
of common stock of the Issuer, for an aggregate of 37.0% based on 2,487,727
total outstanding shares.
ITEM 6. CONTRACTS, ARRANGEMENTS, UNDERSTANDINGS OR RELATIONSHIPS WITH
RESPECT TO SECURITIES OF THE ISSUER.
N/A
ITEM 7. MATERIAL TO BE FILED AS EXHIBITS.
N/A
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SIGNATURES
After reasonable inquiry and to the best of my knowledge and belief, I
hereby certify that the information set forth in this statement is true,
complete and correct.
Dated: February 10, 2000
/s/ John B. van der Hagen
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Signature
John B. van der Hagen, Chief Executive Officer
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Name/Title
/s/ Mary van der Hagen
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Signature
Mary van der Hagen, Secretary
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Mary van der Hagen, Secretary
Name/Title
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