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OMB APPROVAL
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OMB Number: 3235-0104
Expires: December 31, 2001
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 3
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
(Print or Type Responses)
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1. Name and Address of Reporting Person*
Coulter James G.
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(Last) (First) (Middle)
345 California Street, Suite 3300
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(Street)
San Francisco CA 94104
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(City) (State) (Zip)
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2. Date of Event Requiring Statement (Month/Day/Year)
11/15/99
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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
Genesis Health Ventures, Inc. (GHV)
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5. Relationship of Reporting Person to Issuer
(Check all applicable)
[X] Director [_] 10% Owner
[_] Officer (give title below) [_] Other (specify below)
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6. If Amendment, Date of Original (Month/Day/Year)
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7. Individual or Joint/Group Filing
[X] Form Filed by One Reporting Person
[_] Form Filed by More than One Reporting Person
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Table I -- Non-Derivative Securities Beneficially Owned
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<TABLE>
<CAPTION>
3. Ownership Form:
2. Amount of Securities Direct (D) or
1. Title of Security Beneficially Owned Indirect (I) 4. Nature of Indirect Beneficial Ownership
(Instr. 4) (Instr. 4) (Instr. 5) (Instr. 5)
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<S> <C> <C> <C>
Common Stock, par value
$0.02 per share 6,250,000 I Owned by TPG Advisors II, Inc. (1)
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</TABLE>
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
* If the form is filed by more than one Reporting Person, see Instruction
5(b)(v).
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 control number.
<PAGE>
FORM 3 (continued)
Table II -- Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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<TABLE>
<CAPTION>
5. Owner-
3. Title and Amount of Securities ship
Underlying 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
---------------------- or Exercise (D) or Indirect
Date Expira- Number Price of Indirect Beneficial
1. Title of Derivative Exer- tion of Derivative (I) Ownership
Security (Instr. 4) cisable Date Title Shares Security (Instr. 5) (Instr. 5)
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<S> <C> <C> <C> <C> <C> <C> <C>
Warrants Issue 11/14/2009 Common Stock 1,000,000 $5.00 I Owned by TPG
Date Advisors II,
Inc. (1)
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Series H Senior Issue None Common Stock 13,228,604 $8.75 I Owned by TPG
Convertible Date Advisors II,
Participating Inc. (1)
Cumulative Preferred
Stock
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Series I Senior Issue None Non Voting 9,571,452 $8.75 I Owned by TPG
Convertible Date Common Stock, Advisors II,
Participating par value $0.02 Inc. (1)
Cumulative Preferred per share
Stock
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</TABLE>
** Intentional misstatements or omissions of facts constitute Federal
Criminal Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 1001 and 15 U.S.C. 78ff(a).
/s/ James G. Coulter November 24, 1999
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**Signature of Reporting Person Date
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.
<PAGE>
Continuation Sheet to Form 3
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Name and Address of Reporting Person James G. Coulter
345 California Street, Suite 3300
San Francisco, California 94104
Issuer Name and Ticker or Trading Symbol Genesis Health Ventures, Inc. (GHV)
Date of Event Requiring Statement November 15, 1999
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Explanation of Responses
(1) James G. Coulter ("Coulter") is a director, officer and stockholder of TPG
Advisors II, Inc. ("TPG Advisors II"), which is the general partner of TPG
GenPar II, L.P., which in turn is the sole general partner of each of TPG
Partners II, L.P. ("Partners II"), TPG Parallel II, L.P. ("Parallel II"),
TPG Investors II, L.P. ("Investors II") and TPG MC Coinvestment, L.P ("TPG
MC" and, together with Partners II, Parallel II and Investors II, the "TPG
Parties"), which are the direct owners of all of the securities reported
herein. TPG Advisors II, as the general partner of the general partner of
each of the TPG Parties, may be deemed, pursuant to Rule 13d-3 under the
Securities Exchange Act of 1934, as amended (the "Exchange Act"), to
beneficially own all of the securities disclosed on this Form 3. Pursuant
to Rule 16a-1(a)(2)(ii)(B) of the Exchange Act, Coulter is deemed to be the
beneficial owner of the shares owned by TPG Advisors II or the TPG Parties
only to the extent of the greater of his direct or indirect interest in the
profits or capital accounts of such entities. Pursuant to Rule 16a-1(a)(4)
under the Exchange Act, this filing shall not be deemed an admission that
Coulter is, for purposes of Section 16 of the Exchange Act or otherwise,
the beneficial owner of any securities beneficially owned by TPG Advisors
II or the TPG Parties in excess of such amount.
