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- -------- U.S. SECURITIES AND EXCHANGE COMMISSION -----------------------------
FORM 3 WASHINGTON, D.C. 20549 OMB APPROVAL
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INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES OMB Number: 3235-0104
Expires: September 30, 1998
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Estimated average burden
Section 17(a) of the Public Utility Holding Company Act of 1935 or hours per response .... 0.5
Section 30(f) of the Investment Company Act of 1940 -----------------------------
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1. Name and Address of Reporting Person* 2. Date of Event Re- 4. Issuer Name and Ticker or Trading Symbol
quiring Statement
Ortenzio, Robert A.. (Month/Day/Year) Centennial HealthCare Corporation (CTEN)
(1)
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(Last) (First) (Middle) 3. IRS or Social Se- 5. Relationship of Reporting Person 6. If Amendment, Date
curity Number of to Issuer (Check all applicable) of Original
Reporting Person X Director 10% Owner (Month/Day/Year)
4718 Old Gettysburg Road (Voluntary) ---- ----
Officer (give Other (specify
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title below) below)
(Street)
Mechanicsburg, PA 17055
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(City) (State) (Zip) 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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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
(Instr. 4) (D) or Indirect (Instr. 4)
(I) (Instr. 5)
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Common Stock 1,299(2) D
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* If the Form is filed by more than one Reporting Person, see Instruction 5(b)(v).
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
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(Print or Type Responses)
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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 2. Date Exer- 3. Title and Amount of Securities 4. Conver- 5. Owner- 6. Nature of
(Instr. 4) cisable and Underlying Derivative Security sion or ship Indirect
Expiration (Instr. 4) Exercise Form of Beneficial
Date Price of Deriv- Ownership
(Month/Day/ Deriv- ative (Instr. 5)
Year) ative Security:
-------------------------------------------------- Security Direct
Amount (D) or
Date Expir- or Indirect
Exer- ation Title Number (I)
cisable Date of (Instr. 5)
Shares
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Explanation of Responses:
(1) Date of effectiveness of the Registration Statement on Form S-1 filed by the Issuer in connection with its initial public
offering, estimated to be on or about July 1, 1997.
(2) Reflects .6897-for-1 reverse stock split effective the date of the event requiring this statement.
/s/ Robert A. Ortenzio 6-30-97
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**Intentional misstatements or omissions of facts constitute Federal **Signature of Reporting Person Date
Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). Robert A. Ortenzio
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)
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