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:
John A. Dore
222 N. LaSalle, Suite 1600
Chicago, Illinois 60601
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):
September 2000
6. Relationship of Reporting Person(s) to Issuer (Check all
applicable):
(x) Director ( ) 10% Owner (x) 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)
----------- --------- ---------- ---------------------- ---------------- ------------- ---------------------
Code V Amount (A)or(D) Price
---- - ------ -------- -----
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
Common 12/29/00 P 142,857 A $1.75 D
Stock,
$.01 par
value(1)
Common 12/30/00 A 7,407 A $1.88 311,264(2) D
Stock,
$.01 par
value
Common 2,000 I IRA
Stock,
$.01 par
value
Common 4,000 I Keough
Stock,
$.01 par
value
Common 2,600 I As trustee for
Stock, Christopher L. Dore
$.01 par
value
Common 3,565 12,165 I As trustee for
Stock, John A. Dore II
$.01 par
value
(1) Each share of Common Stock was sold as a Unit that consisted of one share of Common Stock of the Company and
five-year Common Stock purchase Warrant. The purchase price of each Unit was $1.75, and the Warrant exercise
price is $1.925, subject to adjustment.
(2) Includes 7,407 shares acquired under the employee stock purchase plan in December 2000.
</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)
---------- ------- ------- ---------- ---------- --------------- ---------------- -------- -------- -------- -------
Code V (A) (D) Date
---- - --- --- Exer- Expir- Amount or
cis- ation Number of
able Date Title Shares
----- ------ ----- ---------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
Warrant $1.925 12/29/00 P 142,857 12/29/00 12/29/05 Common 142,857 (1) 142,857 D
Stock
$.01
par
value
</TABLE>
Explanation of Responses:
(1) Each Warrant was sold as part of a Unit that consisted of one
share of Common Stock of the Company and one five-year Common
Stock purchase Warrant. The purchase price of each Unit was
$1.75, and the Warrant exercise price is $1.925, subject to
adjustment.
SIGNATURE OF REPORTING PERSON:
/s/ John A. Dore
------------------------------
John A. Dore
Dated: January 10, 2001
