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FORM 5 OMB Approval
U.S. SECURITIES AND EXCHANGE COMMISSION --------------------------
[X] Check this box if no longer WASHINGTON, D.C. 20549 OMB Number 3235-0362
subject to Section 16. Form Expires: February 1, 1994
4 or Form 5 obligations may ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Estimated average burden
continue. See Instruction 1(b). hours per response......0
[ ] Form 3 Holdings Reported Filed pursuant to Section 16(a) of the Securities
[ ] Form 4 Transactions Reported and Exchange Act of 1934, Section 17(a) of the
Public Utility Holding Company Act of 1935 or Section 30(f)
of the Investment Company Act of 1940.
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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 Issuer (Check all applicable)
Forum Capital Partners JPS Packaging -- JPSP _____ Director __X__ 10% Owner
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(Last) (First) (Middle) 3. IRS or Social 4. Statement for _____ Other (specify below)
Security Number Month/Year 7. Individual or Joint/Group Reporting
One Oxford Centre, Suite 3950 of Reporting 12/99 (check applicable)
- ---------------------------------------- Person (Voluntary) ------------------------ __X__ Form Filed by One Reporting
(Street) 5. If Amendment, Date Person
of Original (Month/Year) _____ Form Filed by More than One
Pittsburgh PA 15219 25-1798043 Reporting Person
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(City) (State) (Zip) Table I - Non Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1. Title of Security 2.Transaction 3.Transaction 4.Securities Acquired (A) 5.Amount of 6.Owner 7.Nature
(Instr. 3) Date Code or Disposed of (D) Securities ship of
(Month/Day/ (Instr. 8) (Instr. 3, 4, and 5) Beneficially Form: Indirect
Year) Owned at End Direct Bene-
--------------------------------------- of Issuer's (D) or ficial
Amount (A) Price Fiscal Year Indirect Owner-
or (Instr. 3 (I) ship
(D) and 4) (Instr.4)(Instr.4)
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JPS Packaging 734,000 D
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Reminder: Report on a separate line for each class of securities beneficially owned, directly or indirectly. (Over)
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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 Security 2.Conversion 3.Transaction 4.Transaction 5.Number of 6.Date Exer- 7.Title and Amount
(Instr. 3) or Exercise Date Code Derivative cisable and of Underlying
Price of (Instr. 8) Securities Expiration Date Securities
Derivative (Month/Day/ Acquired (A) (Month/Day/Year) (Instr. 3 and 4)
Security Year) or Disposed
of (D) --------------------------------------
(Instr. 3, Date Expir- Amount or
4, and 5) Exer- ation Title Number of
-------------- cisable Date Shares
(A) (D)
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N/A
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8.Price of 9.Number of 10.Ownership 11.Nature of
Derivative Derivative Form of Indirect
Security Securities Derivative Beneficial
(Instr. 5) Beneficially Security; Ownership
Owned at End Direct (D) or (Instr. 4)
of Year Indirect (I)
(Instr. 4) (Instr. 4)
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Explanation of Responses:
*Increase in share amount reflects 100% stock dividend payable
12-15-96 to shareholders of record on 12-1-96.
JOHN A. STALEY, IV 2/15/00
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*Signature of Reporting Person Date
(POA on file)
** 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 signed.
If space provided is insufficient, see Instruction 6 for procedure.
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