U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 4
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).
================================================================================
1. Name and Address of Reporting Person*
KORNSTEIN DON R.
- --------------------------------------------------------------------------------
(Last) (First) (Middle)
1110 PALMS AIRPORT DRIVE
- --------------------------------------------------------------------------------
(Street)
LAS VEGAS NV 89119
- --------------------------------------------------------------------------------
(City) (State) (Zip)
================================================================================
2. Issuer Name and Ticker or Trading Symbol
JACKPOT ENTERPRISES, INC. (J)
================================================================================
3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
###-##-####
================================================================================
4. Statement for Month/Year
September 1999
================================================================================
5. If Amendment, Date of Original (Month/Year)
================================================================================
6. Relationship of Reporting Person to Issuer
(Check all applicable)
|X| Director |_| 10% Owner
|X| Officer (give title below) |_| Other (specify below)
PRESIDENT, CHIEF EXECUTIVE OFFICER AND DIRECTOR
================================================================================
7. Individual or Joint/Group Filing (Check Applicable Line)
|X| Form filed by one Reporting Person
|_| Form filed by more than one Reporting Person
================================================================================
* If the Form is filed by more than one Reporting Person, see Instruction
4(b)(v).
================================================================================
Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
================================================================================
<TABLE>
<CAPTION>
6.
4. 5. Owner-
Securities Acquired (A) or Amount of ship
3. Disposed of (D) Securities Form: 7.
Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of
2. Code ---------------------------- Owned at End (D) or Indirect
1. Transaction (Instr. 8) (A) of Month Indirect Beneficial
Title of Security Date ------------ Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) Code V (D) and 4) (Instr.4) (Instr. 4)
- ------------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
</TABLE>
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
Page 1 of 2
<PAGE>
FORM 4 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
================================================================================
<TABLE>
<CAPTION>
9. 10.
Number Owner-
of ship
2. Deriv- Form of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
of Derivative 6. of Underlying 8. ities Secur- of
Exer- 4. Securities Date Securities Price Bene- ity: In-
cise 3. Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- action or Disposed Expiration Date --------------------- Deriv- Owned (D) or Bene-
1. of action Code of(D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date (Instr. (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ 8) 4 and 5) Date Expira- Number ity Month (I) ship
Security Secur- Day/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4)
- ------------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
- ------------------------------------------------------------------------------------------------------------------------------------
Option to Buy $9.2500 09/08/95 09/08/04 Common Stock 233333 233333 D
Common Stock Par Value $.01
- ------------------------------------------------------------------------------------------------------------------------------------
Option to Buy $9.2500 09/08/96 09/08/04 Common Stock 233333 233333 D
Common Stock Par Value $.01
- ------------------------------------------------------------------------------------------------------------------------------------
Option to Buy $9.2500 09/08/97 09/08/04 Common Stock 233334 233334 D
Common Stock Par Value $.01
- ------------------------------------------------------------------------------------------------------------------------------------
Option to Buy $10.7500 09/30/95 06/30/00 Common Stock 27500 27500 D
Common Stock Par Value $.01
- ------------------------------------------------------------------------------------------------------------------------------------
Option to Buy $10.0000 09/30/96 06/30/01 Common Stock 27500 27500 D
Common Stock Par Value $.01
- ------------------------------------------------------------------------------------------------------------------------------------
Option to Buy $11.5000 09/30/97 06/30/02 Common Stock 27500 27500 D
Common Stock Par Value $.01
- ------------------------------------------------------------------------------------------------------------------------------------
Option to Buy $9.9375 09/30/98 06/30/03 Common Stock 27500 27500 D
Common Stock Par Value $.01
- ------------------------------------------------------------------------------------------------------------------------------------
Option to Buy 8.7500 6/30/99 A 27500 09/30/99 06/30/04 Common Stock 27500 8.7500 27500 D
Common Stock Par Value $.01
- ------------------------------------------------------------------------------------------------------------------------------------
Option to Buy 9.0000 9/14/99 A 15000 09/14/00 09/14/09 Common Stock 15000 9.0000 15000 D
Common Stock Par Value $.01
- ------------------------------------------------------------------------------------------------------------------------------------
Option to Buy 9.0000 9/14/99 A 15000 09/14/01 09/14/09 Common Stock 15000 9.0000 15000 D
Common Stock Par Value $.01
====================================================================================================================================
</TABLE>
Explanation of Responses:
** Intentional misstatements or omissions of facts constitute Federal Criminal
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
/s/ Don R. Kornstein 10/12/99
- --------------------------------------------- -----------------------
** Signature of Reporting Person Date
Note: File three copies of this Form, one of which must be manually signed. If
space provided is insufficient, see Instruction 6 for procedure.
Page 2 of 2
