UNITED STATES SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
FORM 4
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
( ) Check this box if no longer subject to Section 16. Form 4 or
Form 5 obligations may continue. See Instructions 1(b).
1. Name and Address of Reporting Person:
Wilmer J. Thomas, Jr.
101 Selleck Hill Road
Salisbury, Connecticut 06068
U.S.A.
2. Issuer Name and Ticker or Trading Symbol:
American Country Holdings Inc.
ACHI
3. IRS or Social Security Number of Reporting Person (Voluntary):
4. Statement for Month/Year:
December 2000
5. If Amendment, Date of Original (Month/Year):
August 1997
6. Relationship of Reporting Person(s) to Issuer (Check all
applicable):
(x) Director (x) 10% Owner ( ) Officer (give title below)
( ) Other (specify below):
7. Individual or Joint/Group Filing (Check Applicable Line):
(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
<TABLE>
<CAPTION>
5. Amount of
2. Trans- Securities 6. Owner-
action 3. Trans- Beneficially ship Form:
1. Title of Date action 4. Securities Acquired Owned at End Direct (D) or 7. Nature of Indirect
Security (Month/ Code (A) or Disposed of (D) of Month Indirect (I) Beneficial Ownership
(Instr. 3) Day/Year) (Instr. 8) (Instr. 3, 4 and 5) (Instr. 3 and 4) (Instr. 4) (Instr. 4)
----------- --------- ---------- ---------------------- ---------------- ------------- ---------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
Code V Amount (A)or(D) Price
---- - ------ -------- -----
</TABLE>
Table II -- Derivative Securities Acquired,
Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
<TABLE>
<CAPTION>
10.
9. Owner-
5. Number ship
2. Number of Deri- Form of 11.
Conver- of Deriv- vative Deri- Nature
sion or ative Securi- vative of
Exer- Secur- ties Secur- Indi-
cise 3. ities 7. 8. Benefi- ity: rect
1. Price Trans- Acquired 6. Title and Price cially Direct Benefi-
Title of of action 4. (A) or Date Exer- Amount of of Deriv- Owned at (D) or cial
Deriv- Deriv- Date Trans- Disposed cisable and Underlying ative End of Indirect Owner-
ative ative (Month/ action of (D) Expiration Securities Security Month (I) ship
Security Secur- Day/ Code (Instr. 3, Date(Month/ (Instr. 3 (instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) (Instr. 8) 4 and 5) Day/Year) and 4) 5) 4) 4) 4)
---------- ------- ------- ---------- ---------- --------------- ---------------- -------- -------- -------- -------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
Code V (A) (D) Date
---- - --- --- Exer- Expir- Amount or
cis- ation Number of
able Date Title Shares
----- ------ ----- ---------
Series A (1) 12/29/00 100,000 12/29/00 Common 571,428(2) $ 10 100,000 D
6% Con- Stock
vertible $.01
Preferred par
Stock value
</TABLE>
Explanation of Responses:
(1) The Series A 6% Convertible Preferred Stock has a stated value of
$10 per share. The conversion price of the Preferred Stock is
$1.75, subject to adjustment. Each share of Preferred Stock is
convertible into such number of shares of Common Stock by
dividing the stated value, plus accrued but unpaid dividends by
the then effective conversion price. The terms of the Preferred
Stock are set forth in the Certificate of Designations,
Preferences, and Rights of Series A Convertible Preferred Stock.
(2) Subject to antidilution adjustment.
SIGNATURE OF REPORTING PERSON:
/s/ Wilmer J. Thomas, Jr.
------------------------------
Wilmer J. Thomas, Jr.
Dated: January 10, 2001
