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- ------------------------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION ------------------------------
FORM 3 Washington, D.C. 20549 OMB Approval
- ------------------------- INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES ------------------------------
OMB Number: 3235-0104
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Expires: December 31, 2001
Section 17(a) of the Public Utility Holding Company Act of 1935 or Estimated average burden
Section 30(f) of the Investment Company Act of 1940 hours per response.......0.5
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(Print or Type Responses)
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1. Name and Address of Reporting Person* 2. Date of Event Requiring 4. Issuer name and Ticker or Trading Symbol
Statement (Month/Day/Year)
11/22/99 Official Payments Corporation, OPAY
Cohan, Andrew -----------------------------------------------------------------------------------------
------------------------------------ 3. I.R.S. Identification 5. Relationship of Reporting 6. If Amendment, Date of
(Last) (First) (Middle) Number of Reporting Person(s) to Issuer Original
Person, if an entity (Check all applicable) (Month/day/Year)
c/o Official Payments Corporation (Voluntary)
2333 San Ramon Valley Boulevard [X] Director
Suite 450
------------------------------------ [ ] Officer ----------------------------
(Street) (give title below) 7. Individual or Joint/Group
[ ] 10% Owner Filing
[ ] Other (Check Applicable Line)
San Ramon, CA 94583 (specify below) [X] Form Filed by One
------------------------------------ Reporting Person
(City) (State) (Zip) [ ] Form Filed by More
------------------------- than One Reporting
Person
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TABLE I NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
<S> <C> <C> <C>
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1. Title of Security 2. Amount of Securities 3. Ownership Form: Direct (D) 4. Nature of Indirect
(Instr. 4) Beneficially Owned or Indirect (I) (Instr. 5) Beneficial Ownership
(Instr. 4) (Instr. 5)
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
*If the form is filed by more than one reporting person, see Instruction 5(b)(v).
POTENTIAL PERSONS WHO ARE TO RESPOND TO THE COLLECTION OF INFORMATION CONTAINED IN THIS FORM
ARE NOT REQUIRED TO RESPOND UNLESS THE FORM DISPLAYS A CURRENTLY VALID OMB CONTROL NUMBER
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SEC 1473 (3-99)
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FORM 3 (CONTINUED)
TABLE II-- DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
<S> <C> <C> <C> <C> <C>
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1. Title of 2. Date Exer- 3. Title and Amount of 4. Conversion or 5. Ownership 6. Nature of
Derivative cisable and Securities Underlying Exercise Price Form of Indirect
Security Expiration Derivative Security of Derivative Derivative Beneficial
(Instr. 4) Date (Instr. 4) Security Security: Ownership
(Month/Day/Year) Direct (D) or (Instr. 5)
Indirect (I)
(Instr. 5)
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Date Expira- Title Amount or
Exer- tion Number of
cisable Date Shares
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Option to purchase Immed. 11/28/09 Common Stock, 93,750 $15.00 D
(1) par value $0.01
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Explanation of Responses:
(1) ONE-THIRD OF THE OPTION VESTS AFTER ONE YEAR, AND THE REMAINING TWO-THIRDS VESTS IN EQUAL MONTHLY INSTALLMENTS FOR 24 MONTHS
THEREAFTER.
** 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 /s/ Cohan, Andrew 12/10/99
signed. If space is insufficient, see Instruction 6 for ------------------------------------ -------------------
procedure. ** Signature of Reporting Person Date
Potential persons who are to respond to the collection of information contained in this form
are not required to respond unless the form displays a currently valid OMB control number.
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SEC 1473 (3-99)
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