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- ---------- U.S. SECURITIES AND EXCHANGE COMMISSION -------------------------------
FORM 4 WASHINGTON, DC 20549 OMB APPROVAL
- ---------- OMB NUMBER: 3235-0287
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP EXPIRES: SEPTEMBER 30, 1998
/ / Check box if no ESTIMATED AVERAGE BURDEN
longer subject to Filed pursuant to Section 16(a) of the Securities HOURS PER RESPONSE........ 0.5
Section 16. Form 4 Exchange Act of 1934, Section 17(a) of the --------------------------------
or Form 5 obligations Public Utility Holding Company Act of 1935
may continue. See or Section 30(f) of the Investment Company
Instruction 1(b). Act of 1940
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1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person to
PASQUALE DOUGLAS M. ARV ASSISTED LIVING, INC. (SRS) Issuer (Check all applicable)
- --------------------------------------------- ---------------------------------------------- X Director 10% Owner
(Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- ---
245 FISCHER AVENUE, SUITE D-1 Number of Reporting Month/Year X Officer Other
- --------------------------------------------- Person (Voluntary) 04/99 ----(give title ---(Specify below)
(Street) ------------------ below)
COSTA MESA CA 92626 5. If Amendment,
- --------------------------------------------- Date of Original President, Chairman and Chief
(City) (State) (Zip) (Month/Year) Executive 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 1 -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of Se- 6. Ownership 7. Nature of
(Instr. 3) action action or Disposed of (D) curities Benefi- Form: Indirect
Date Code (Instr. 3, 4 and 5) cially Owned at Direct Beneficial
(Instr. 8) End of Month (D) or Ownership
---------- -------------- ------------------------- Indirect
(Month/ Code V Amount (A) or Price (I)
Day/ (D) (Instr. 3 and 4) (Instr. 4) (Instr. 4)
Year)
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
*If the form is filed by more than one reporting person, see Instruction 4(b)(v). SEC 1474 (7-96)
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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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1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price
Security sion or action action Derivative cisable and of Underlying of
(Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv-
Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative
Deriv- Day/ Disposed of (D) (Month/Day/ Secur-
ative Year) (Instr. 3, 4, Year) ity
Security and 5) (Instr. 5)
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Code V (A) (D) Date Expira- Title Amount or
Exer- tion Number of
cisable Date Shares
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Employee Stock $3.00 04/14/99 A V 50,000 04/14/00 04/14/09 Common 50,000 $3.00
Option (Right to Buy) Stock
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Employee Stock $3.00 04/14/99 A V 50,000 04/14/01 04/14/09 Common 50,000 $3.00
Option (Right to Buy) Stock
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Employee Stock $3.00 04/14/99 A V 50,000 04/14/02 04/14/09 Common 50,000 $3.00
Option (Right to Buy) Stock
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1. Title of Derivative 9. Number of 10. Ownership 11. Nature of
Security Derivative Form of Indirect
(Instr. 3) Securities Derivative Beneficial
Beneficially Security: Ownership
Owned at End Direct (D) (Instr. 4)
of Month or Indirect (I)
(Instr. 4) (Instr. 4)
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Employee Stock D
Option (Right to Buy)
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Employee Stock D
Option (Right to Buy)
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Employee Stock 300,000 D
Option (Right to Buy)
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Explanation of Responses:
**Intentional misstatements or omissions of facts constitute Federal Criminal /s/ Douglas M. Pasquale May 10, 1999
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------------- ------------
**Signature of Reporting Person Date
Note. File three copies of this form, one of which must be manually signed. Page 2
If space provided is insufficient, see Instruction 6 for procedure. SEC 1474 (7-96)
Potential persons who are to respond to the collection of information contained
in this form are not required to respond unless the form displays a currently
valid OMB number.
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