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OMB APPROVAL
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------ OMB Number 3235-0104
FORM 3 Expires: December 31, 2001
------ Estimated average burden
hours per response ....... 0.5
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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 Ralph P
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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. Date of Event Requiring Statement (Month/Day/Year)
November 23, 1999
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Issuer Name and Ticker or Trading Symbol
Frontier Adjusters of America, Inc. (FAJ)
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5. Relationship of Reporting Person to Issuer (Check all applicable)
[ ] Director [X] 10% Owner (1)
[ ] Officer (give title below) [ ] Other (specify below)
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6. If Amendment, Date of Original (Month/Year)
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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 3 (continued)
Table I -- Non-Derivative Securities Beneficially Owned
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3. Ownership Form:
1. Title of 2. Amount of Securities Direct (D) or 4. Nature of Indirect
Security Beneficially Owned Indirect (I) Beneficial Ownership
(Instr. 4) (Instr. 4) (Instr. 5) (Instr.5)
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Common Stock None (2)
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Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
<TABLE>
<CAPTION>
Table II -- Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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<S> <C> <C> <C> <C> <C>
3. Title and Amount 5.Owner-
of Securities Underlying ship
Derivative Security Form of
2. Date Exercisable (Instr. 4) Derivative
and Expiration Date ------------------------ 4. Conver- Security:
(Month/Day/Year) Amount sion or Direct 6. Nature of
1. Title of -------------------- or Exercise (D) or Indirect
Derivative Date Expira- Number Price of Indirect Beneficial
Security Exer- tion of Derivative (I) Ownership
(Instr. 4) cisable Date Title Shares Security (Instr.5) (Instr. 5)
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</TABLE>
Explanation of Responses:
/s/ Ralph P. 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 4. The
Reporting Person disclaims beneficial ownership of these securities and the
filing of this Form 3 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 provided is insufficient. See Instruction 6 for procedure.
