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- ---------- U.S. SECURITIES AND EXCHANGE COMMISSION -------------------------------
FORM 4 WASHINGTON, DC 20549 OMB APPROVAL
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STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OMB NUMBER: 3235-0287
[ ] Check this box if no EXPIRES: DECEMBER 31, 2001
longer subject to Filed pursuant to Section 16(a) of the Securities ESTIMATED AVERAGE BURDEN
Section 16. Form 4 Exchange Act of 1934, Section 17(a) of the HOURS PER RESPONSE 0.5
or Form 5 obligations Public Utility Holding Company Act of 1935 --------------------------------
may continue. See or Section 30(f) of the
Instruction 1(b). Investment Company Act of 1940
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(Print or Type Responses)
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1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s)
to Issuer (Check all applicable)
KHOURY ABDO H. ARV ASSISTED LIVING, INC. (SRS) Director 10% Owner
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(Last) (First) (Middle) 3. IRS Identification 4. Statement for X Officer Other
Number of Reporting Month/Year --- (give title ---(Specify title
245 Fischer Avenue, Suite D-1 Person if an entity December 1999 below) below)
- --------------------------------------------- (Voluntary) ------------------- Senior Vice President and Chief
(Street) 5. If Amendment, Financial Officer
Date of Original --------------------------------
Costa Mesa California 92626 Original 7. Individual or Joint/Group Filing
- --------------------------------------------- (Month/Year) (Check Applicable Line)
(City) (State) (Zip) 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 6. Ownership 7. Nature of
(Instr. 3) action action or Disposed of (D) Securities Form: Indirect
Date Code (Instr. 3, 4 and 5) Beneficially Direct (D) Beneficial
(Instr. 8) Owned at or Ownership
---------- -------------- ------------------------- End of Month Indirect (I) (Instr. 4)
(Month/ (Instr. 3 and 4) (Instr. 4)
Day/
Year)
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(A) or
Code V Amount (D) Price
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COMMON STOCK 12/29/99 P 2,000 A $1.50 2,300 D
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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 (3-99)
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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. Transaction 5. Number of 6. Date Exer- 7. Title and 8. Price of
Security sion or action Code Derivative cisable and Amount of Derivative
(Instr. 3) Exercise Date (Instr. 8) Securities Expiration Underlying Security
Price of (Month/ Acquired (A) Date Securities (Instr. 5)
Derivative Day/ or Disposed of (Month/Day/ (Instr.
Security Year) (D) (Instr. 3, Year) 3 and 4)
4, and 5)
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Date Expira- Amount or
Exer- tion Number of
cisable Date Title Shares
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Code V (A) (D)
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EMPLOYEE STOCK OPTION $1.625 12/20/99 A V 33,334 12/20/00 12/20/09 COMMON 33,334
(RIGHT TO BUY)(1) STOCK
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EMPLOYEE STOCK OPTION $1.625 12/20/99 A V 33,333 12/20/01 12/20/09 COMMON 33,333
(RIGHT TO BUY)(1) STOCK
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EMPLOYEE STOCK OPTION $1.625 12/20/99 A V 33,333 12/20/02 12/20/09 COMMON 33,333
(RIGHT TO BUY)(1) STOCK
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EMPLOYEE STOCK OPTION $1.625 12/20/99 A V 50,000 (2) 12/20/09 COMMON 50,000
(RIGHT TO BUY)(1) 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 OPTION D
(RIGHT TO BUY)(1)
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EMPLOYEE STOCK OPTION D
(RIGHT TO BUY)(1)
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EMPLOYEE STOCK OPTION D
(RIGHT TO BUY)(1)
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EMPLOYEE STOCK OPTION 150,000 D
(RIGHT TO BUY)(1)
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Explanation of Responses:
(1) THESE ENTRIES RELATE TO A SINGLE OPTION GRANT ON DEECMBER 20, 1999.
(2) THIS PORTION OF THE OPTION GRANT WILL VEST IN THREE ANNUAL INSTALLMENTS
BEGINNING ON THE FIRST DAY OF THE QUARTER IMMEDIATELY FOLLOWING THE
ACHIEVEMENT BY THE COMPANY OF BOTH A POSITIVE CASH FLOW AND PROFITABILITY,
BUT WILL IN NO CASE BEGIN VESTING LATER THAN DECEMBER 20, 2004.
**Intentional misstatements or omissions of facts constitute Federal Criminal /s/ ABDO H. KHOURY February 1, 2000
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). -------------------------- ----------------
Abdo H. Khoury Date
**Signature of
Reporting Person
Note: File three copies of this Form, one of which must be manually signed. Page 2
If space is insufficient, see Instruction 6 for procedure. SEC 1474 (3-99)
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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