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FORM 4 OMB APPROVAL
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[ ] Check this box if no longer OMB Number 3235-0287
subject to Section 16. Form 4 Expires: December 31, 2001
or Form 5 obligations may Estimated average burden
continue. See Instruction 1(b). hours per response............. 0.5
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UNITED STATES 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
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1. Name and Address of Reporting Person*
Gulick III John Alexander
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(Last) (First) (Middle)
c/o H.E.R.C. Products Incorporated
2215 West Melinda Lane, Suite A
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(Street)
Phoenix Arizona 85027
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
H.E.R.C. Products Incorporated ("HERC")
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3. IRS Or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
December 2000
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person(s) to Issuer (Check all applicable)
[ ] Director [ ] 10% Owner
[X] Officer (give title below) [ ] Other (specify below)
Vice President
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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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<PAGE>
Form 4 (continued)
<TABLE>
<CAPTION>
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TABLE I--NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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<S> <C> <C> <C> <C> <C> <C>
1.Title of 2. Trans- 5. Amount of 6. Owner-
Security action 3. Trans- 4. Securities Acquired (A) Securities ship
(Instr. 3) Date action or Disposed of (D) Beneficially Form: 7. Nature of
(Month/ Code (Instr. 3, 4 and 5) Owned at Direct Indirect
Day/ (Instr. 8) ---------------------- End of Month (D) or Beneficial
Year) ---------- (A) or (Instr. 3 and 4) Indirect I) Ownership
Code V Amount (D) Price (Instr. 4) (Instr. 4)
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Common Stock 12/22/00 P 10,000 A $.1875 D
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Common Stock 12/22/00 P 5,000 A $.20 D
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Common Stock 12/26/00 P 35,500 A $.20 D
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Common Stock 12/26/00 P 20,000 A $.18 D
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Common Stock 12/27/00 P 1,242 A $.20 D
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Common Stock 12/29/00 P 48,258 A $.20 D
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Common Stock 12/29/00 P 35,000 A $.18 155,000 D
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Table II--DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivative 2. Conver- 3. Trans- 4. Transac- 5. Number of Derivative
Security (Instr. 3) sion or action tion Securities Acquired
Exercise Date Code (A) or Disposed
Price of (Month/ (Instr. 8) of (D)(Instr. 3,4, and 5)
Derivative Day/ ----------- -------------------------
Security Year) Code V (A) (D)
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Employee Stock Option
(Right to Buy) $.30 1/1/00 A V 20,000
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6. Date Exercisable 9. Number
and Expiration 7. Title and Amount of of Derivative 10. Ownership
Date (Month/ Underlying Securities ative Form of
Day/Year) (Instr. 3 and 4) Securities Derivative 11. Nature of
---------------- -------------------- 8. Price of Beneficially Security: Indirect
Date Expira- Amount or Derivative Owned at Direct (D) Beneficial
Exer- tion Number of Security End of Month or Indirect Ownership
cisable Date Title Shares (Instr.5) (Instr. 4) (I)(Instr.4) (Instr.4)
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(1) 12/31/07 Common Stock 20,000 20,000 D
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</TABLE>
Explanation of Responses:
/s/ John Alexander Gulick III January 10, 2001
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**Signature of Reporting Person Date
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(1) Options to purchase 10,000 shares vest and become exercisable on December
31, 2000, and options to purchase the remaining 10,000 shares vest and
become exercisable on December 31, 2001.
** Intentional misstatements or omissions of facts constitute Federal Criminal
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
