FORM 4
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 this 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
InMed, Inc. d/b/a Incap, Inc.
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(Last) (First) (Middle)
2200 Ross Avenue, Suite 4200 West
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(Street)
Dallas, Texas 75201
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Mountasia Entertainment International, Inc. (MBE)
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
02/97
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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)
[ ] Director [ X ] 10% Owner
[ ] Officer (give title below) [ ] Other (specify below)
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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>
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Common Stock 01/15/97 J* 7,802,435 A $3.50 I By MEI
Holdings, L.P.
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Common Stock 01/31/97 J** 384,603 A $ 0 14,419,337 I By MEI
Holdings, L.P.
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</TABLE>
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly
* Represents shares acquired in a tender offer commenced by MEI Holdings, L.P.
("MEI Holdings") on November 14, 1996 which expired on January 14, 1997 (the
"Tender Offer"). MEI Holdings is required to vote the shares of Common Stock
acquired in the Tender Offer (to the extent that the Common Stock beneficially
owned by MEI Holdings and its affiliates exceed 49.9% of all outstanding shares
of Common Stock at the time in question) in the same proportion as the shares of
Common Stock held by persons other than MEI Holdings are voted.
** Represents shares issued under the Warrant granted to MEI Holdings on August
28, 1996 (the "Warrant") which provides, as anti-dilution protection, for the
issuance to MEI Holdings, without the payment of additional consideration, of
shares of Common Stock or Series F Preferred Stock of the issuer upon the
conversion, redemption or repayment of certain convertible securities of the
issuer.
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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>
9. 10.
Number Owner-
of ship
2. Deriv- of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
of 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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Series G
Preferred Stock $ 0 1/15/97 J (A) *** *** Common 2,135,513 $22.60 2,135,513 I By MEI
213,551 Stock Holdings,
L.P.
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Series F
Preferred Stock $ 0 1/15/97 J (A) **** **** Common 17,272,991 ***** 17,272,991 I By MEI
1,727,299 Stock Holdings,
L.P.
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</TABLE>
Explanation of Responses:
*** Series G Preferred Stock is economically equivalent to ten shares of Common
Stock, is nonvoting except in certain limited circumstances and is convertible
into Common Stock at a rate of 10 shares of Common Stock per share of Series G
Preferred Stock upon shareholder approval of such conversion. Represents shares
issued in consideration of MEI Holdings' funding of the issuer's redemption of
its $4.5 million 10% Convertible Subordinated Debentures. The purchase price
per share of Series G Preferred Stock is subject to upward adjustment in
certain circumstances.
**** Series F Preferred Stock is economically equivalent to ten shares of Common
Stock, is nonvoting except in certain limited circumstances and is convertible
into Common Stock at a rate of 10 shares of Common Stock per share of Series F
Preferred Stock upon shareholder approval of such conversion. Represents (a)
447,752 shares issued upon MEI Holdings' conversion of certain debentures of the
issuer having an aggregate principal amount of $15.6 million that were acquired
by MEI Holdings in the Tender Offer, (b) 377,773 shares that MEI Holdings
believes are issuable pursuant to the Warrant upon conversion of such debentures
and other convertible securities of the issuer and pursuant to certain valuation
adjustments provided for in the Investment Agreement between the issuer and MEI
Holdings entered into in June, 1996 (the "Investment Agreement") and (c) the
estimated 901,774 shares issuable to MEI Holdings' following the issuer's
exercise of its right, under the Investment Agreement, to require MEI Holdings
to invest $22.7 million. The number of shares issued under the Warrant and for
the $22.7 million investment are subject to adjustment upon the occurrence of
certain events outside MEI Holdings' control.
***** The purchase price for the 447,752 shares referred to in clause (a) of the
previous footnote was $35.00 per share and for the 901,774 shares in clause (c)
(which is subject to adjustment) was $2.52 per share (or $2.14 per share if the
shareholder approval referred to above is not obtained). The 377,773 shares
referred to in clause (b) were acquired for no additional consideration.
InMed, Inc.
February 10, 1997
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**Signature of Reporting Person Date
Daniel A. Decker
Executive Vice President
** 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 procedures.
