<PAGE>
FORM 5
/ / Check box if no longer OMB APPROVAL
subject to Section 16. OMB NUMBER: 3235-0362
Form 4 or Form 5 EXPIRES: SEPTEMBER 30, 1998
obligations may continue. ESTIMATED AVERAGE BURDEN
See Instruction 1(b) HOURS PER RESPONSE 1.0
/ / Form 3 Holdings Reported
/ / Form 4 Transactions Reported
U.S. SECURITIES AND EXCHANGE
COMMISSION
Washington, D.C. 20549
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
1. Name and Address of Reporting Person*
Kopp Larry S.
(Last) (First) (Middle)
2023 Narrows View Circle, B-212
(Street)
Gig Harbor Washington 98335
(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Financial Services Acquisition Corporation
(Common Stock: "FSAT"; Series A Warrants: "FSATW")
3. IRS or Social Security Number of Reporting Person (Voluntary)
4. Statement for Month/Year
12/96
5. If Amendment, Date of Original (Month/Year)
6. Relationship of Reporting Person(s) to Issuer (Check all applicable)
( X ) Director ( ) 10% Owner
( ) Officer (give title below) ( ) Other (specify below)
7. Individual or Joint/Group Filing (Check applicable line)
( X ) Form filed by One Reporting Person
( ) Form filed by More than One Reporting Person
* If Form is filed by more than one Reporting Person, see Instruction 4(b)(v).
(Print or Type Responses) Page 1
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<TABLE>
<CAPTION>
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security 2. Transaction Date 3. Transaction Code 4. Securities Acquired (A) or
(Instr. 3) (Month/Day/Year) (Instr. 8) Disposed of (D)
(Instr. 3, 4 and 5)
-------------------------------------------
Amount (A) or (D) Price
- ------------------------------------- ----------------------- -------------------- ------------- ------------- -------------
<S> <C> <C> <C> <C> <C>
a. Common Stock, par value $.001
- ------------------------------------- ----------------------- -------------------- ------------- ------------- -------------
b.
- ------------------------------------- ----------------------- -------------------- ------------- ------------- -------------
c.
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d.
- ------------------------------------- ----------------------- -------------------- ------------- ------------- -------------
e.
- ------------------------------------- ----------------------- -------------------- ------------- ------------- -------------
f.
- ------------------------------------- ----------------------- -------------------- ------------- ------------- -------------
<CAPTION>
5. Amount of Securities Beneficially 6. Ownership Form: 7. Nature of Indirect
Owned at End of Issuer's Fiscal Year Direct (D) or Indirect (I) Beneficial Ownership
(Instr. 3 and 4) (Instr. 4) (Instr. 4)
- ------------------------------------------ ---------------------------------- ----------------------------------
<S> <C> <C>
a. 33,000 D
- ------------------------------------------ ---------------------------------- ----------------------------------
b.
- ------------------------------------------ ---------------------------------- ----------------------------------
c.
- ------------------------------------------ ---------------------------------- ----------------------------------
d.
- ------------------------------------------ ---------------------------------- ----------------------------------
e.
- ------------------------------------------ ---------------------------------- ----------------------------------
f.
- ------------------------------------------ ---------------------------------- ----------------------------------
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
</TABLE>
(Print or Type Responses) Page 2
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<TABLE>
<CAPTION>
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g, puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security 2. Conversion or 3. Transaction Date 4. Transaction 5. Number of Derivative Securities
(Instr. 3) Exercise Price (Month/Day/Year) Code Acquired (A) or Disposed of (D)
of Derivative (Instr. 8) (Instr. 3, 4 and 5)
Security ----------------------------------
(A) (D)
- --------------------------------- ----------------- -------------------- --------------- ----------------- ----------------
<S> <C> <C> <C> <C> <C>
a. Series A Redeemable Common $5.00
Stock Purchase Warrants
- --------------------------------- ----------------- -------------------- --------------- ----------------- ----------------
b. Options - Right to Buy $5.00 (1) A 10,000
- --------------------------------- ----------------- -------------------- --------------- ----------------- ----------------
c.
- --------------------------------- ----------------- -------------------- --------------- ----------------- ----------------
d.
- --------------------------------- ----------------- -------------------- --------------- ----------------- ----------------
e.
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f.
- --------------------------------- ----------------- -------------------- --------------- ----------------- ----------------
<CAPTION>
6. Date Exercisable 7. Title and Amount of Underlying 8. Price of 9. Number of 10. Ownership 11. Nature of
and Expiration Securities Derivative Derivative Form of Indirect
Date (Instr. 3 and 4) Security Securities Derivative Beneficial
(Month/Day/Year) (Instr. 5) Beneficially Security: Ownership
- --------------------------- --------------------------------- Owned at Direct (D) (Instr. 4)
Date Expiration Title Amount or End of Year or Indirect
Exercisable Date Number of (Instr. 4) (I)
Shares
- --------------- ----------- ----------------- -------------- -------------- -------------- --------------- --------------
<S> <C> <C> <C> <C> <C> <C> <C>
a. Immediate 11/30/01 Common Stock 21,000 21,000 D
- --------------- ----------- ----------------- -------------- -------------- -------------- --------------- --------------
b. (1) 08/26/06 Common Stock 10,000 10,000 D
- --------------- ----------- ----------------- -------------- -------------- -------------- --------------- --------------
c.
- --------------- ----------- ----------------- -------------- -------------- -------------- --------------- --------------
d.
- --------------- ----------- ----------------- -------------- -------------- -------------- --------------- --------------
e.
- --------------- ----------- ----------------- -------------- -------------- -------------- --------------- --------------
f.
- --------------- ----------- ----------------- -------------- -------------- -------------- --------------- --------------
</TABLE>
Explanation of Responses:
(1) Options were all granted on August 27, 1996 under the issuer's 1996 stock
option plan and have 10 year terms (unless the reporting person's service
as a director of the issuer terminates earlier). 50% of the options become
exercisable 6 months from the date of grant and 50% of the options become
exercisable 1 year from the date of grant.
/s/ Larry S. Kopp February 14, 1997
- --------------------------------- ----------------------
** Signature of Reporting Person 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.
(Print or Type Responses) Page 3
