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OMB APPROVAL
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OMB Number 3235-0362
Expires: December 31, 2001
Estimated average burden
hours per response ....... 1.0
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 5
ANNUAL 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).
[ ] Form 3 Holdings Reported
[ ] Form 4 Transactions Reported
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1. Name and Address of Reporting Person*
Flores Brenda W.
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(Last) (First) (Middle)
One Mikasa Drive
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(Street)
Secaucus New Jersey 07096
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Mikasa, Inc., (MKS)
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
December 1999
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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 [ ] 10% Owner
[ X ] Officer (give title below) [ ] Other (specify below)
Vice President and Chief Financial Officer
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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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Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
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<TABLE>
<CAPTION>
5. 6.
4. Amount of Owner-
Securities Acquired (A) or Securities ship
Disposed of (D) Beneficially Form: 7.
(Instr. 3, 4 and 5) Owned at End Direct Nature of
2. 3. ----------------------------- of Issuer's (D) or Indirect
1. Transaction Transaction (A) Fiscal Year Indirect Beneficial
Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) (Instr. 8) (D) & 4) (Instr.4) (Instr. 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C>
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</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.
Page 1 of 2
<PAGE>
FORM 5 (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
or Derivative 6. of Underlying 8. ities Secur- of
Exer- Securities Date Securities Price Bene- ity: In-
cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship
Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) 8) (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>
Employee Stock $9.9375 12/10/99 J* 25,000 * 12/10/09 Common 25,000 82,500 D
Option (right to Stock
buy)
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</TABLE>
Explanation of Responses:
*Stock Option Grant to reporting person to purchase shares of common stock, par
value $.01, under the Mikasa Inc., 1998 Long-Term Incentive Plan in a
transaction exempt under old Rule 16b-3. The options become exercisable one
year from the date of grant for one half of the remaining shares and two years
from the date of grant for the remaining shares.
/s/ Brenda W. Flores 02/02/00
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Brenda W. Flores 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.
Alternatively, this Form is permitted to be submitted to the Commission in
electronic format at the option of the reporting person pursuant to Rule
101(b)(4) of Regulation S-T.
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