FORM 4
[_] Check box if no longer subject
to Section 16. Form 4 or Form
5 obligations may continue.
See Instruction 1(b).
U.S. SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
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
- --------------------------------------------------------------------------------
1. Name and Address of Reporting Person*
Katz Stephen
(Last) (First) (Middle)
20 East Sunrise Highway, Suite 200
(Street)
Valley Stream NY 11581
(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Coin Bill Validator, Inc. -- CBVI
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3. IRS or Social Security 4. Statement for 5. If Amendment,
Number of Reporting Month/Year Date of Original
Person (Voluntary) 01/97 (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)
VICE CHAIRMAN OF THE BOARD AND CHIEF EXECUTIVE OFFICER
------------------------------------------------------
7. Individual or Joint/Group Filing
(Check applicable line)
[X] Form filed by one Reporting Person
[_] Form filed by more than one Reporting Person
================================================================================
<TABLE>
<CAPTION>
TABLE I - NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
====================================================================================================================================
1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired 5. Amount of 6. Owner- 7. Nature
(Instr. 3) action action (A) or Disposed of (D) Securities ship of In-
Date Code (Instr. 3, 4 and 5) Beneficially Form: direct
(Instr. 8) Owned at Direct Bene-
(Month/ End of (D) or ficial
Day/ ------------ -------------------------- Month Indirect Owner-
Year) Code V Amount (A) or Price (Instr. 3 and 4) (I) ship
(D) (Instr.4) (Instr.4)
====================================================================================================================================
<S> <C> <C> <C> <C>
Common Stock,
par value $.01 5/21/96 Z 1,000 D -0- D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock,
par value $.01 6/24/96 Z 2,500 D -0- D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock,
par value $.01 6/26/96 Z 9,700 D -0- 492,020 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock,
par value $.01 12/13/96 Z 29,500 D -0- 462,520 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock,
par value $.01 1/2/97 P 10,000 A $70,000 472,520 D
====================================================================================================================================
</TABLE>
* 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)
SEC 1474 (8-92)
<PAGE>
FORM 4 (CONTINUED)
TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY
OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
FORM 4
(CONTINUED)
TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF,
OR BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS,
OPTIONS, CONVERTIBLE SECURITIES)
<TABLE>
<CAPTION>
==========================================================================================
1. Title of 2. Conver- 3. Trans- 4. Transac- 5. Number of
Derivative sion or action tion Derivative
Security Exer- Date Code Securities
(Instr. 3) cise (Month/ Acquired (A)
Price Day/ (Instr. 8) or Disposed
of Year) of (D)
Deriv-
ative (Inst. 3, 4, and 5)
Security
- ------------------------------------------------------------------------------------------
Code V (A) (D)
- ------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C>
-- -- -- -- -- -- --
==========================================================================================
</TABLE>
<TABLE>
<CAPTION>
==============================================================================================================
6. Date Exer- 7. Title and Amount 8. Price 9. Number 10. Owner 11. Nature
cisable and of Underlying of of Deriv- ship of Indirect
Expiration Securities Deriv- ative Form Beneficial
Date ative Secur- of Ownership
(Month/Day/ (Instr. 3 and 4) Secur- ities Deri-
Year) ity Bene- vative (Instr. 4)
(Instr. 5) ficially Secu-
Owned rity:
at End Direct
of Month (D) or
Indi-
(Instr. 4) rect (I)
(Instr. 4)
- --------------------------------------------------------------------------------------------------------------
Amount
Date Expi- or
Exer- ration Title Number
cisable Date of
Shares
- ------- ------- ----- ------
<S> <C> <C> <C> <C> <C> <C> <C>
-- -- -- -- -- -- -- --
==============================================================================================================
</TABLE>
Explanation of Responses:
Mr. Katz holds 462,520 common shares indicated in Table 1 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 that is the beneficial owner of
200,000 common shares subject to the voting trust. The shares disposed of were
withdrawn from the voting trust by, and distributed to, certain beneficiaries of
the voting trust. On January 2, 1997, Mr. Katz acquired and beneficially owns,
individually, and not as the voting trustee, 10,000 common shares.
** Intentional misstatements or omissions of facts constitute Federal Criminal
Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). **Signature of Reporting Person:
/s/ Stephen Katz 2/3/97
---------------- ------
Stephen Katz Date
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 1474 (8-92)
