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-------- U.S. SECURITIES AND EXCHANGE COMMISSION ---------------------------
FORM 3 WASHINGTON, DC 20549 OMB APPROVAL
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INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES OMB Number: 3235-0104
Expires: December 31, 2001
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Estimated average burden
Section 17(a) of the Public Utility Holding Company Act of 1935 hours per response......0.5
or Section 30(f) of the Investment Company Act of 1940 ---------------------------
(Print or Type Responses)
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1. Name and Address of Reporting Person* 2. Date of Event 4. Issuer Name and Ticker or 6. If Amendment,
Requiring Statement Trading Symbol Date of Original
ALARCON MICHELLE (Month/Day/Year)
---------------------------------------- April 20, 2001 ARV Assisted Living, Inc. (SRS)
(Last) (First) (Middle) ---------------------------- ---------------------------------- -----------------------
3. IRS or Social Security 5. Relationship of Reporting 7. Individual or Joint/
245 FISCHER AVENUE, #D-1 Number of Reporting Person(s) to Issuer Group Filing (Check
---------------------------------------- Person (Voluntary) (Check all applicable) applicable line)
(Street)
---------------------------- Director 10% Owner X Form filed by
COSTA MESA, CALIFORNIA 92626 ----- ----- ----- One Reporting
---------------------------------------- Person
(City) (State) (Zip) X Officer Other
----- (give title ----- (specify Form filed by
below) below) ----- More than One
Reporting Person
Senior Vice President, Human Resources
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TABLE 1 -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
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1. Title of Security 2. Amount of Securities 3. Ownership Form: 4. Nature of Indirect
(Instr. 4) Beneficially Owned Direct (D) or Beneficial Ownership
(Instr. 4) Indirect (I) (Instr. 4)
(Instr. 5)
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. Page 1
*If the form is filed by more than one Reporting Person, see Instruction 5(b)(v). SEC 1473 (7-96)
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FORM 3 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
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1. Title of Derivative Security 2. Date Exercisable 3. Title and Amount of 4. Conversion 5. Ownership 6. Nature of
(Instr. 4) and Expiration Securities Underlying or Exercise Form of Indirect
Date (Month/ Derivative Security Price of Derivative Beneficial
Day/Year) (Instr. 4) Derivative Security: Ownership
------------------------------------------------- Security Direct (D) (Instr. 5)
Date Amount or or Indirect(I)
Exercis- Expiration Number of (Instr. 5)
able Date Title Shares
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Employee Stock Option
(Right to Buy) (1) 12/13/10 Common Stock 35,000 0.5625 D
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Explanation of Responses:
(1) The options vest in three equal installments over a three year period. The first installment will vest on the first day of the
quarter immediately following the Company achieving a positive cash flow and profitability for two consecutive quarters and
the second and third installments will vest on the first and second anniversaries of such date, respectively, provided that in
no case will vesting begin later than December 14, 2005.
/s/ MICHELLE ALARCON May 10, 2001
** Intentional misstatements or omissions of facts constitute Federal ------------------------------- ------------
Criminal 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.
If space provided is insufficient, See Instruction 6 for procedure.
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 Page 2
SEC 1473 (7-96)