U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 5
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities 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.
[ ] Check this box if no longer subject to Section 16.
Form 4 or Form 5 obligations may continue. See Instruction 1(b).
[X] Form 3 Holdings Reported [X] Form 4 Holdings Reported
1. Name and Address of Reporting Person:
Omar A. Rizvi, Esq., LL.M.
175 North Harbor Drive, Apt. 4502
Chicago, Illinois 60601
2. Issuer Name and Ticker or Trading Symbol:
Origin Investment Group, Inc.
OTC-Bulletin Board Symbol = OGNI
3. IRS or Social Security Number of Reporting Person (Voluntary):
4. Statement for Month/Year: December 1999
5. If Amendment, Date of Original (Month/Day/Year):
None
6. Relationship of Reporting Person to Issuer (Check all applicable):
___X___ Director ___X___ 10% Owner
___X___ Officer (give title below) ____ Other (specify below)
Chairman of the Board, President
7. Individual or Joint/Group Filing: [X] Form filed by One Reporting Person
[ ] Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
1. Title of Security:
Common Stock, par value $.001
2. Transaction Date (Month/Year):
May, 1999
3. Transaction Code:
D
4. Securities Acquired (A) or Disposed of (D): (A) 1,000,000
5. Amount of Securities Beneficially Owned at End of Issuer's Fiscal Year:
1,000,000
6. Ownership Form: Direct (D) or Indirect (I):
(D)
7. Nature of Indirect Beneficial Ownership:
None
Table II - Derivative Securities Acquired, Disposed of,
or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security:
12/23/2002 Options (1999 Employee Stock Incentive Plan)
2. Conversion or Exercise Price of Derivative Security:
$.10 per share
3. Transaction Date (Month/Day/Year):
11/29/1999
4. Transaction Code:
A
5. Number of Derivative Securities Acquired (A) or Disposed of
(D): (A) 100,000 - 12/23/2002 Options
6. Date Exercisable and Expiration Date:
Date Exercisable: 12/23/1999
Expiration Date: 12/23/2002
7. Title and Amount of Underlying Securities
Title: Common Stock
Amount or Number of Shares: 100,000
8. Price of Derivative Security
$.10 per share
9. Number of Derivative Securities Beneficially Owned at End of Year:
100,000 Options
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
Direct
11. Nature of Indirect Beneficial Ownership:
None
Explanation of Responses:
/s/ Omar A. Rizvi
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**Signature of Reporting Person
2/14/00
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Date
