U.S. SECURITIES AND EXCHANGE COMMISSION OMB APPROVAL
WASHINGTON, D.C. 20549
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FORM 3 OMB APPROVAL
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OMB Number 3235-0104
Expires: April 30, 1997
Estimated average burden
hours per response...0.5
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
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1. Name and Address of Reporting Person
Katz Stephen
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(Last) (First) (Middle)
20 East Sunrise Highway, Suite 200
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(Street)
Valley Stream NY 11581
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(City) (State) (Zip)
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2. Date of Event Requiring
Statement
(Month/Day/Year)
5/23/96
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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
Coin Bill Validator, Inc.-- CBVI
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5. Relationship of Reporting Person to Issuer
(Check all applicable)
X Director X 10% Owner
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X Officer (give title below Other (specify below)
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Vice Chairman of the Board of Directors
and Chief Executive Officer
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6. If Amendment, Date of Original (Month/Day/Year)
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<TABLE>
<CAPTION>
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TABLE I -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
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1. Title of Security 2. Amount of Securities 3. Ownership 4. Nature of Indirect
(Instr. 4) Beneficially Owned Form: Direct Beneficial Ownership
(D) or Indirect (Intr. 5)
(Instr. 4) (I) (Instr. 5)
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<S> <C> <C>
Common Stock, par value $.01 835,220 D
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</TABLE>
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly. (Over)
(Print or Type Responses) SEC 1473 (8-92)
<PAGE>
FORM 3 (CONTINUED)
TABLE II - DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS, CALLS,
WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
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1. Title of Derivative Security (Instr. 4)
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2. Date Exercisable and Expiration Date (Month/Day/ Year)
Date
Exercisable Expiration Date
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3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
Amount or
Number of
Title Shares
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4. Conversion or Exercise Price of Deri- vative Security
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5. Ownership Form of Derivative Security:
Direct (D) or Indirect (I) (Instr. 5)
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6. Nature of Indirect Beneficial Ownership (Instr. 5)
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Explanation of Responses:
Mr. Katz holds the shares of Common Stock indicated in Item 2 of Table
I solely as the voting trustee under a Voting Trust Agreement dated as of May
23, 1996 relating to such shares, and Mr. Katz disclaims beneficial ownership of
such shares, as such. Mr. Katz is also a partner of a general partnership which
is the beneficial owner of 200,000 shares of Common Stock subject to the above
voting trust.
/S/ Stephen Katz 5/30/96
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Stephen Katz Date
** 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.
Page 2
SEC 1473 (8-92)
