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FORM 5
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/ / Check box if no U.S. SECURITIES AND EXCHANGE COMMISSION
longer subject to WASHINGTON, DC 20549
Section 16. Form
4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
obligations may
continue. See Filed pursuant to Section 16(a) of the Securities
Instruction 1(b) Exchange Act of 1934,
/ / Form 3 Holdings Section 17(a) of the Public Utility
Reported Holding Company Act of 1935 or Section 30(f) of
/ / Form 4 the Investment Company Act
Transactions of 1940
Reported
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<S> <C> <C> <C> <C> <C> <C>
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1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person to
Huizenga H. Wayne Psychemedics Corporation (PMD) Issuer (Check all applicable)
- ------------------------------------------- ---------------------------------------------- Director X 10% Owner
(Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- ---
450 E. Las Olas Blvd. Number of Reporting Month/Year Officer (give Other (specify
- ------------------------------------------- Person (Voluntary) 1996 ---- title --- below)
(Street) ------------------- below)
Ft. Lauderdale, FL 33301 5. If Amendment,
- ------------------------------------------- Date of Original -------------------------------
(City) (State) (Zip) (Month/Year)
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 1 -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature
(Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In-
Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct
(Instr. 8) End of Issuer's Direct Benefi-
(Month/ Fiscal Year (D) or cial
Day/ ---------------------------- (Instr. 3 and 4) Indirect Owner-
Year) Amount (A) or Price (I) ship
(D) (Instr. 4) (Instr.
4)
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Common Stock, $.005 par value 12/30/96 J(1) 1,583,467 D N/A 764,938(2) D
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Common Stock, $.005 par value 12/30/96 J(1) 1,583,467 A N/A 1,583,467 I (3)
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Common Stock, $.005 par value 8,386(4) I (5)
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*If the form is filed by more than one Reporting Person, see Instruction 4(b)(v).
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
(Print or Type Responses) (8/96)
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FORM 5 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
<S> <C> <C> <C> <C> <C> <C> <C>
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1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price
Security sion or action action Derivative cisable and of Underlying of
(Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv-
Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative
Deriv- Day/ Disposed of (D) (Month/Day/ Secur-
ative Year) (Instr. 3, 4, Year) ity
Security and 5) (Instr. 5)
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Date Expira- Amount or
--------------- Exer- tion Title Number of
(A) (D) cisable Date Shares
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<C> <C> <C> <C>
1. Title of Derivative 9. Number of 10. Ownership 11. Nature of
Security Derivative of Derivative Indirect
(Instr. 3) Securities Security: Beneficial
Beneficially Direct (D) Ownership
Owned at End or Indirect (I) (Instr. 4)
of Year (Instr. 4)
(Instr. 4)
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Explanation of Responses:
(1) Mr. Huizenga transferred these shares of Common Stock to Huizenga
Investments Limited Partnership.
(2) Includes 68,399 shares of Common Stock received as a result of a 3% stock
dividend paid by the Issuer on July 3, 1996.
(3) These shares are owned by Huizenga Investments Limited Partnership, a
Nevada limited partnership, controlled by Mr. Huizenga.
(4) Includes 244 shares of Common Stock received as a result of a 3% stock
dividend paid by the Issuer on July 3, 1996.
(5) These shares are owned by Mr. Huizenga's wife and Mr. Huizenga disclaims
beneficial ownership of such shares.
**Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ H. Wayne Huizenga 2/14/97
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------------- -------
**Signature of Reporting Person Date
H. Wayne Huizenga
Note. File three copies of this form, one of which must be manually signed. Page 2
If space provided is insufficient, see Instruction 6 for procedure. (8/96)
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