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FORM 4 OMB APPROVAL
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[ ] Check this box if no longer OMB Number 3235-0287
subject to Section 16. Form 4 Expires: December 31, 2001
or Form 5 obligations may Estimated average burden
continue. See Instruction 1(b). hours per response............. 0.5
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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
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1. Name and Address of Reporting Person*
Pascucci Michael C
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(Last) (First) (Middle)
270 South Service Road, Suite 45
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(Street)
Melville New York 11747-2339
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(City (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Frontier Adjusters of America, Inc. (FAJ)
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3. IRS Or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
December 2000
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person(s) to Issuer (Check all applicable)
[ ] Director [X] 10% Owner (1)
[ ] Officer (give title below) [ ] Other (specify below)
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7. Individual or Joint/Group Filing (Check Applicable Line)
[X] Form filed by One Reporting Person
[ ] Form filed by More than One Reporting Person
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<PAGE>
Form 4 (continued)
<TABLE>
<CAPTION>
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TABLE I--NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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<S> <C> <C> <C> <C> <C> <C>
1.Title of Security 2.Trans- 3.Trans- 4.Securities Acquired (A) 5.Amount of 6.Owner- 7.Nature of
(Instr. 3) action action or Disposed of (D) Securities ship Indirect
Date Code (Instr. 3, 4 and 5) Beneficially Form: Beneficial
(Month/ (Instr. 8) Owned at Direct Owner-
Day/ ---------- ---------------------- End of Month (D) or ship
Year) (A) or (Instr. 3 and 4) Indirect I) (Instr. 4)
Code V Amount (D) Price (Instr. 4)
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Common Stock 11/27/00 P 1,300 A 1,872.00 D
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Common Stock 11/28/00 P 10,500 A 20,036.10 11,800(2) D
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Table II--DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivative 2. Conver- 3. Trans- 4. Transac- 5. Number of Derivative
Security (Instr. 3) sion or action tion Securities Acquired
Exercise Date Code (A) or Disposed
Price of (Month/ (Instr. 8) of (D)(Instr. 3,4, and 5)
Derivative Day/ ----------- -------------------------
Security Year) Code V (A) (D)
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6.Date Exer- 7.Title and Amount of 8.Price 9.Number 10.Owner- 11. Nature
cisable and Underlying Securities of of Deriv- ship of
Expiration (Instr. 3 and 4) Deriv- ative Form of Indirect
Date (Month/ ative Securities Deriv- Benefi-
Day/Year) Security Bene- ative cial
---------------- -------------------- (Instr.5) ficially Security: Owner-
Date Expira- Title Amount or Owned at Direct (D) ship
Exer- tion Number of End of Month or Indirect (Instr.4)
cisable Date Shares (Instr. 4) (I)(Instr.4)
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</TABLE>
Explanation of Responses:
/s/ Michael C. Pascucci December 29, 2000
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**Signature of Reporting Person Date
(1) The Reporting Person may be deemed to share voting and dispositive power
over the shares of Common Stock of the Issuer described in Item 2. The
Reporting Person disclaims beneficial ownership of these securities and the
filing of this Form 4 shall not be deemed an admission that the Reporting
Person is a beneficial owner or has voting or dispositive power over such
securities for any purposes under the Act.
(2) Does not include 5,258,513 shares owned by United Financial Adjusting
Company with regard to which the Reporting Person disclaims any beneficial
interest.
** 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 insufficient, 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.
