5/A: Annual statement of changes in beneficial ownership of securities
Published on September 10, 2001
U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 5/A
AMENDED 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 box if no longer subject to 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*
Erickson Thomas W.
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(Last) (First) (Middle)
3106 Greenbriar Drive
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(Street)
Dallas TX 75225
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Omega Healthcare Investors, Inc. (OHI)
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Statement for Month/Year
12/00
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5. If Amendment, Date of Original (Month/Year)
February 2001
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6. Relationship of Reporting Person to Issuer
(Check all applicable)
[X] Director [_] 10% Owner
[X] Officer (give title below) [_] Other (specify below)
Interim President and CEO
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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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* 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.
(Print or Type Responses) (Over)
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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Explanation of Responses:
*Options to acquire 10,000 shares of common stock at an exercise price of $6.25
per share were granted to the undersigned on July 17, 2000. Options are
exercisable as to one third of the shares after July 17, 2001, as to an
additional one-third of the shares after July 17, 2002 and as to the remaining
balance after July 17, 2003, all at an exercise price of $6.25. Options expire
10 years from the date of grant.
**Options to acquire 35,000 shares of common stock at an exercise price of $6.25
per share were granted to the undersigned on October 1, 2000. The options are
exercisable from the date of grant until the earlier of (i) the tenth
anniversary of the grant date; (ii) termination by new CEO for cause or
(iii) November 1, 2005. Options vest on May 1, 2001.
/s/ THOMAS W. ERICKSON September 10, 2001
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**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.
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