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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
Expires: September 30, 1998
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Estimated average burden
Section 17(a) of the Public Utility Holding Company Act of 1935 or hours per response .... 0.5
(Print or Type Responses) Section 30(f) of the Investment Company Act of 1940 -----------------------------
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<S><C>
1. Name and Address of Reporting Person* 2. Date of Event Re- 4. Issuer Name AND Ticker or Trading Symbol
quiring Statement
Ellin Robert S. (1) (Month/Day/Year) Forward Industries, Inc. (FORD)
- ------------------------------------------------- -----------------------------------------------------------
(Last) (First) (Middle) 10/9/98 5. Relationship of Reporting Person(s) 6. If Amendment,
----------------------- to Issuer (Check all applicable) Date of Original
(Month/Day/Year)
c/o Atlantis Equities, Inc.
750 Lexington Avenue -------------------
3. IRS or Social Se- Director X 10% Owner
curity Number of ---- ----
Reporting Person Officer (give Other (specify
- ------------------------------------------------- (Voluntary) title below) below) 7. Individual or
(Street) ---- ---- Joint/Group Filing
(Check Applicable
Line)
- --------------------------- Form filed by One
Reporting Person
---
Form filed by
More than One
X Reporting Person
New York, NY 10022 ---
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(City) (State) (Zip) TABLE I -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
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1. Title of Security 2. Amount of Securities 3. Ownership 4. Nature of Indirect Beneficial
(Instr. 4) Beneficially Owned Form: Direct Ownership (Instr. 5)
(Instr. 4) (D) or Indirect
(I) (Instr. 5)
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Common Stock, par value $.01 per share 17,500 D
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Common Stock, par value $.01 per share 189,000 I By Atlantis Equities, Inc.
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Common Stock, par value $.01 per share 37,500 I By Robert Ellin Family 1997
Trust
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Common Stock, par value $.01 per share 8,000 I By Robert Ellin Profit
Sharing Plan, as Trustee
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Page 1 of 3 Pages
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1. Title of Derivative Security 2. Date Exer- 3. Title and Amount of Securities 4. Conver- 5. Owner- 6. Nature of Indirect
(Instr. 4) cisable and Underlying Derivative Security sion or ship Beneficial
Expiration (Instr. 4) Exercise Form of Ownership
Date Price of Deriv- (Instr. 5)
(Month/Day/ Deri- ative
Year) vative Security:
-------------------------------------------------- Security Direct
Amount (D) or
Date Expir- or Indirect
Exer- ation Title Number (I)
cisable Date of
Shares (Instr. 5)
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Warrants 12/9/98 3/15/99 Common Stock (2) 108,000 $4.00 D
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Warrants 12/9/98 3/15/99 Common Stock (2) 15,000 $4.00 I By Atlantis
Equities, Inc.
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Warrants 12/9/98 3/15/99 Common Stock (2) 75,000 $4.00 I By Robert Ellin
Profit Sharing
Plan
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Class B Warrants 3/25/96 12/11/98 Common Stock 91,500 $5.00 I By Atlantis
Equities, Inc.
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Explanation of Responses:
(1) Pursuant to Instruction 5(b)(v), this Form 3 is filed jointly by all of the /s/ Robert S. Ellin 10/19/98
undersigned (collectively, the "Reporting Persons"), who may be deemed to be members ------------------------------ --------
of a "group" pursuant to Section 13(d) of the Securities Exchange Act of 1934, as **Signature of Reporting Person Date
amended. Robert S. Ellin ("Purchaser") has been designated to make the filing of
this Form 3.
(2) The Reporting Persons acquired these securities in the Company's private offering of
securities consisting of units ("Units") consummated on December 4, 1997,
each Unit comprised of (i) 30,000 shares of the Company's Common Stock, $.01 par
value ("Common Stock"), (ii) one warrant ("Warrant") to purchase up to 30,000 shares
of Common Stock at $4.00 per share and (iii) one unsecured convertible promissory
note ("Note") in the principal amount of $10,000, bearing interest at a rate of 10%
per annum (convertible at the sole option of the Company under certain circumstances,
into 20,000 shares of Common Stock and one Warrant) maturing on December 4, 1998. The
foregoing statement does not include principal amount of Notes held by Mr. Ellin,
Atlantis Equities, Inc. and Robert Ellin Profit Sharing Plan in the amounts of
$36,000, $5,000 and $25,000, respectively.
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** 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 signed.
If space is sufficient, SEE Instruction 6 for procedure.
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 Number.
SEC 1473 (9-96)
Page 2 of 3 Pages
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FORM 3 (CONTINUED)
Joint Filer Information
Name: Robert S. Ellin
Address: c/o Atlantis Equities, Inc.
750 Lexington Avenue
New York, NY 10022
Name: Atlantis Equities, Inc.
Address: c/o Atlantis Equities, Inc.
750 Lexington Avenue
New York, NY 10022
Name: Robert Ellin Family 1997 Trust
Address: c/o Marvin Ellin, Trustee
106 Central Park South
New York, NY 10019
Name: Robert Ellin Profit Sharing Plan
Address: c/o Atlantis Equities, Inc.
750 Lexington Avenue
New York, NY 10022
Designated Filer: Robert S. Ellin
Date of Event Requiring Statement: 10/09/98
Issuer and Ticker or Trading Symbol: Forward Industries, Inc. (FORD)
Signature: /s/ Robert S. Ellin
---------------------------
Robert S. Ellin
ROBERT ELLIN FAMILY 1997 TRUST
By: /s/ Marvin Ellin
---------------------------
Marvin Ellin, Trustee
ATLANTIS EQUITIES, INC.
By: /s/ Robert S. Ellin
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Robert S. Ellin, President
ROBERT ELLIN PROFIT SHARING PLAN
By: /s/ Robert S. Ellin
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Robert S. Ellin, Trustee
Page 3 of 3 Pages
