UNITED STATES THIS IS A COPY OF
SECURITIES AND EXCHANGE COMMISSION THE SCHEDULE 13G
Washington, D.C. 20549 FILED ON FEBRUARY 18,
1997 PURSUANT TO A
RULE 201 TEMPORARY
SCHEDULE 13G HARDSHIP EXEMPTION.
Under the Securities Exchange Act of 1934
(Amendment No. 1)*
Elmer's Restaurants, Inc.
- --------------------------------------------------------------------------------
(Name of Issuer)
Common Stock
- --------------------------------------------------------------------------------
(Title of Class of Securities)
289393100
------------------------------
(CUSIP Number)
*The remainder of this cover page shall be filled out for a reporting person's
initial filing on this form with respect to the subject class of securities, and
for any subsequent amendment containing information which would alter the
disclosures provided in a prior cover page.
The information required in the remainder of this cover page shall not be deemed
to be "filed" for the purpose of Section 18 of the Securities Exchange Act of
1934 ("Act") or otherwise subject to the liabilities of that section of the Act
but shall be subject to all other provisions of the Act (however, see the
Notes).
Page 1 of 7 pages
<PAGE>
SCHEDULE 13G
------------
CUSIP No. 289393100 Page 2 of 7
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1) NAME OF REPORTING PERSON
S.S. OR I.R.S. IDENTIFICATION NO. OF ABOVE PERSON
Herman Goldberg ###-##-####
--------------------------------------------------------------------------
2) CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP*
(a) [ ]
(b) [ ]
3) SEC USE ONLY _____________________________________________________________
4) CITIZENSHIP OR PLACE OF ORGANIZATION
United States of America
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5) SOLE VOTING POWER
NUMBER OF 0
--------------------------------------------------
SHARES
6) SHARED VOTING POWER
BENEFICIALLY
0
OWNED BY --------------------------------------------------
EACH 7) SOLE DISPOSITIVE POWER
REPORTING 0
--------------------------------------------------
PERSON
8) SHARED DISPOSITIVE POWER
WITH
0
--------------------------------------------------
9) AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON
0
--------------------------------------------------------------------------
10) CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN
SHARES* [ ]
--------------------------------------------------------------------------
11) PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (9)
0
--------------------------------------------------------------------------
12) TYPE OF REPORTING PERSON*
IN
--------------------------------------------------------------------------
Page 2 of 7 pages
<PAGE>
Item 1. Issuer
(a) The name of the Issuer is Elmer's Restaurants, Inc.
(b) The Issuer's executive offices are located at 11802 SE Stark Street,
Portland, OR 97216.
Item 2. Reporting Person and Security
(a) This Statement is filed by Mr. Herman Goldberg, an individual.
(b) Mr. Goldberg's business address is 11802 SE Stark Street, Portland,
OR 97216.
(c) Mr. Goldberg is a citizen of the United States of America.
(d) This Statement relates to shares of Common Stock of Elmer's
Restaurants, Inc.
(e) The CUSIP number assigned to the Common Stock of the Issuer is
289393100.
Item 3. Filings Pursuant to Rule 13d-1(b) or 13d-2(b)
Not applicable.
Item 4. Ownership
Not applicable.
Item 5. Ownership of Five Percent or Less of a Class
Mr. Goldberg has ceased to be a beneficial owner of five percent
of the Common Stock of the Issuer.
Item 6. Ownership of More than Five Percent on Behalf of Another Person
Not applicable.
Item 7. Identification and Classification of the Subsidiary Which Acquired
the Security Being Reported on by the Parent Holding Company
Not applicable.
Item 8. Identification and Classification of Members of the Group
Not applicable.
Item 9. Notice of Dissolution of Group
Not applicable.
Page 3 of 7 pages
<PAGE>
Item 10. Certification
Not applicable.
Page 4 of 7 pages
<PAGE>
SIGNATURE
After reasonable inquiry and to the best of my knowledge and belief,
I certify that the information set forth in this statement is true,
complete and correct.
February 12, 1997
-----------------------------------------
Date
ANITA GOLDBERG
-----------------------------------------
Anita Goldberg, Personal Representative
for The Estate of Herman Goldberg
Page 5 of 7 pages
<PAGE>
EXHIBIT INDEX
-------------
Exhibit No. Document
- ----------- --------
Exhibit 1 Letters Testamentary for the Estate of Herman Goldberg
naming Anita Goldberg Personal Representative, dated
June 10, 1996
Page 6 of 7 pages
<PAGE>
Exhibit 1
IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF WASHINGTON
Probate Department
ESTATE OF: )
)
HERMAN GOLDBERG ) No. C960367PE
_____________________________________ )
) LETTERS TESTAMENTARY
Deceased. )
THIS CERTIFIES that the Will of HERMAN GOLDBERG deceased, has been proved
and that ANITA GOLDBERG has/have been and is/are at the date hereof the duly
appointed, qualified, and acting PERSONAL REPRESENTATIVE of the will and the
estate of the above-named decedent.
IN WITNESS WHEREOF, I, a court clerk for the State of Oregon, County of
Washington, in which the proceedings for administration of the above estate
are pending, do hereby subscribe my name and affix the seal of the said court
this 10th day of June, 1996.
WASHINGTON COUNTY CIRCUIT COURT
By CAROLYN HARKLEY
------------------------------------
Court Clerk
**********************************************************
STATE OF OREGON )
) ss
COUNTY OF WASHINGTON )
I, a Circuit Court Clerk of the State of Oregon for Washington County,
do hereby certify that the foregoing copy of Letters Testamentary has been by
me compared with the original, that it is a correct transcript therefrom and
of the whole of such original Letters Testamentary, as the same appear on
file and of record in my office and in my custody and that said Letters are
still in full force and effect.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of said Court this 10th day of June, 1996.
WASHINGTON COUNTY CIRCUIT COURT
By CAROLYN HARKLEY
------------------------------------
Court Clerk
Page 7 of 7 pages
