FORM 3
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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
1. Name and Address of Reporting Person
David Nierenberg
The D3 Family Fund
19605 NE 8th St.
Camas, WA 98607
2. Date of Event Requiring Statement (Month/Day/Year)
9/11/2000
3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary)
N/A
4. Issuer Name and Ticker or Trading Symbol
Pediatric Services of America, Inc. (PSAI.OB)
5. Relationship of Reporting Person(s) to Issuer (Check All Applicable)
/ / Director
/ / Officer (give title below)
Vice President, Programming
/X/ 10% Owner
/ / Other (specify below)
6. If Amendment, Date of Original (Month/Day/Year)
N/A
7. Individual or Joint/Group Filing (Check Applicable Line)
/ / Form filed by One Reporting Person
/X/ Form filed by More than One Reporting Person
Filed by The D3 Family Fund, L.P. and Haredale, Ltd.
Haredale, Ltd.
P.O. Box N-4465, Nassau, New Providence, The Bahamas
<PAGE>
FORM 3 (CONTINUED)
<TABLE>
<CAPTION>
Table 1 -- Non-Derivative Securities Beneficially Owned
-------------------------------- --------------------------------- ------------------------------- ---------------------------
1. Title of Security (Instr. 4) 2. Amount of Securities 3. Ownership Form: Direct 4. Nature of Indirect
Beneficially Owned (Instr. 4) (D) or Indirect (I) Beneficial Ownership
(Instr. 5) (Instr. 5)
-------------------------------- --------------------------------- ------------------------------- ---------------------------
<S> <C> <C> <C>
Common shares 834,930 D
Common shares 30,000 I By Haredale, Ltd.
-------------------------------- --------------------------------- ------------------------------- ---------------------------
</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).
<TABLE>
<CAPTION>
Table II -- Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
------------------------------------------------------------------------------------------------------------------------------
1. Title of Derivative 2. Date Exercisable 3. Title and Amount of 4. Converstion 5. Ownership 6. Nature of
Security (Instr. 4) and Expiration Date Securities or Form of Indirect
(Month/Day/Year) Underlying Exercise Derivative Beneficial
Derivative Security Price of Security: Ownership
(Instr. 4) Derivative Direct (D) (Instr. 5)
Security or Indirect
(I) (Instr.
5)
------------------------ ------------------------
Date Expiration Title Amount
Exercisable Date or
Number
of Shares
----------------------------- ------------ ----------- ------------- ---------- --------------- --------------- --------------
<S> <C> <C> <C> <C> <C> <C>
None
----------------------------- ------------ ----------- ------------- ---------- --------------- --------------- --------------
</TABLE>
Explanation of Reponses:
N/A
/s/ David Nierenberg 9/12/00
------------------------------------- ----------
* Signature of Reporting Person Date
David Nierenberg
President
Nierenberg Investment Management Company, Inc.
The General Partner of The D3 Family Fund, L.P.
