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OMB APPROVAL
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OMB Number: 3235-0362
Expires: October 31, 2001
Estimated average burden
hours per response....1.0
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 5
ANNUAL 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 box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
[_] Form 3 Holdings Reported
[_] Form 4 Transactions Reported
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1. Name and Address of Reporting Person*
PERRIGO DEWEY
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(Last) (First) (Middle)
C/O DENTAL/MEDICAL DIAGNOSTIC SYSTEMS, INC.
6416 VARIEL AVENUE
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(Street)
WOODLAND HILLS CA 91367
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
DENTAL/MEDICAL DIAGNOSTIC SYSTEMS, INC. - DMDS
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Statement for Month/Year
11/99
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person to Issuer (Check all applicable)
[_] Director [_] 10% Owner
[X] Officer (give title below) [_] Other (specify below)
VICE PRESIDENT OF SALES
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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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TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF,
OR BENEFICIALLY OWNED
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<TABLE>
<CAPTION>
5. 6.
4. Amount of Owner-
Securities Acquired (A) or Securities ship
Disposed of (D) Beneficially Form: 7.
(Instr. 3, 4 and 5) Owned at End Direct Nature of
2. 3. ----------------------------- of Issuer's (D) or Indirect
1. Transaction Transaction (A) Fiscal Year Indirect Beneficial
Title of Security Date Code or (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) (Instr. 8) Amount (D) Price and 4) (Instr.4) (Instr. 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C>
COMMON STOCK 11/4/99 P 5,100 A 2.33 5,100 I BY SPOUSE
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COMMON STOCK 86,331 D
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</TABLE>
* If the form is filed by more than one Reporting Person, see Instruction
4(b)(v).
(Over)
SEC 2270 (3-99)
<PAGE>
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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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<TABLE>
<CAPTION>
9. 10.
Number Owner-
of ship
2. Deriv- of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
or Derivative 6. of Underlying 8. ities Secur- of
Exer- Securities Date Securities Price Bene- ity: In-
cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship
Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
COMMON STOCK $2.00 11/11/99 A 15,000 (1) 11/10/09 COMMON 15,000 $2.00 94,133 D
OPTIONS STOCK
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</TABLE>
Explanation of Responses:
(1) THE OPTIONS VEST AND BECOME EXERCISABLE WITH RESPECT TO 3,000 SHARES
EACH YEAR, BEGINNING 11/12/00.
/S/ DEWEY PERRIGO MAY 30, 2000
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**Signature of Reporting Person Date
** 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.
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SEC 2270 (3-99)
