U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 4
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 of Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
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1. Name and Address of Reporting Person*
Queen Andrew
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(Last) (First) (Middle)
777 Yamato Road, Suite 350
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(Street)
Boca Raton FL 33431
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Response USA, Inc. (RSPN)
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Statement for Month/Year
August 2000
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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)
[X] Director [X] 10% Owner
[X] Officer (give title below) [_] Other (specify below)
President
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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>
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Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
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<TABLE>
<CAPTION>
6.
4. 5. Owner-
Securities Acquired (A) or Amount of ship
3. Disposed of (D) Securities Form: 7.
Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of
2. Code ------------------------------- Owned at End (D) or Indirect
1. Transaction (Instr. 8) (A) of Month Indirect Beneficial
Title of Security Date ------------ Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) Code V (D) and 4) (Instr.4) (Instr. 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
Common Stock, $.008 par value 08/16/00 J(1) 616,966(2) A (1) 858,484(2) I By Trust
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Common Stock, $.008 par value 08/16/00 J(1) 1,223,459.96(3) A (1) 1,296,803.40(3) I By Zenex A1,
L.L.C.
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Common Stock, $.008 par value 08/16/00 J(1) 6,209.21(4) A (1) 6,542.77(4) I By Zenex J1,
L.L.C.
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Common Stock, $.008 par value -- -- -- -- -- 409,324 D
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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.
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.
(Print or Type Responses)
(Over)
(Form 4-07/99)
<PAGE>
FORM 4 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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<TABLE>
<CAPTION>
10.
9. Owner-
Number ship
of Form
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- 4. Securities Date Securities Price Bene- ity: In-
cise 3. Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- action or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Code of(D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date (Instr. (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ 8) 4 and 5) Date Expira- Number ity Month (I) ship
Security Secur- Day/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) Code V (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> <C>
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</TABLE>
Explanation of Responses:
(1) Pursuant to Amendment No. 1 to Settlement Agreement dated as of July 19,
2000 by and among Jeffrey Queen, Andrew Queen, Jeffrey Queen and Andrew
Queen Irrevocable Trust U/A January 2, 1998 and the Issuer, the Issuer
delivered to the reporting person the number of shares determined in
accordance with the Agreement at an agreed value of $0.50 per share.
(2) Held directly by the Jeffrey Queen and Andrew Queen Irrevocable Trust U/A
January 2, 1998. The Reporting Person's children are beneficiaries of this
Trust.
(3) Held directly by Zenex A1, L.L.C., of which the Reporting Person is a
member.
(4) Held directly by Zenex J1, L.L.C., of which the Reporting Person is a
member.
By: /s/ Andrew Queen September 8, 2000
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**Signature of Reporting Person Date
Andrew Queen
** 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.
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.
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