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OMB APPROVAL
OMB Number: 3235-0362
Expires: October 31, 2001
------ Extimated average burden
FORM 5 hours per response...1.0
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/ / Check box if no U.S. SECURITIES AND EXCHANGE COMMISSION
longer subject to WASHINGTON, DC 20549
Section 16. Form
4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
obligations may
continue. See Filed pursuant to Section 16(a) of the Securities
Instruction 1(b) Exchange Act of 1934,
/X/ Form 3 Holdings Section 17(a) of the Public Utility
Reported Holding Company Act of 1935 or Section 30(f) of
/ / Form 4 the Investment Company Act
Transactions of 1940
Reported
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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)
Lewis M. Edwards Image Technology Laboratories, Inc. (IMTL) to Issuer (Check all applicable)
--------------------------------------------------------------------------------------------- X Director X 10% Owner
(Last) (First) (Middle) 3. IRS or Identification 4. Statement for ---- ---
Number of Reporting Month/Year X Officer (give Other (Specify
167 Schwenk Dr. Person (Voluntary) August 15, 2000 ---- title --- below)
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(Street) 5. If Amendment, Chief Technical Officer
Date of Original
Kingston, NY 12401 (Month/Year) 7. Individual of Joint/Group Reporting
------------------------------------------- (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. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature
(Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In-
Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct
(Instr. 8) End of Issuer's Direct Benefi-
(Month/ Fiscal Year (D) or cial
Day/ ---------------------------- (Instr. 3 and 4) Indirect Owner-
Year) Amount (A) or Price (I) ship
(D) (Instr. 4) (Instr.
4)
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Common Stock 2,429,583 D
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Preferred Stock 1/00 500,000 A $0.00 500,000 D
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*If the Form is filed by more than one Reporting Person, see Instruction 4(b)(v).
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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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Date Expira- Amount or
--------------- Exer- tion Title Number of
(A) (D) cisable Date Shares
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Options $.33 N/A N/A 1,000,000 * 1/01/10 1,000,000
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1. Title of Derivative 9. Number of 10. Ownership 11. Nature of
Security Derivative of Derivative Indirect
(Instr. 3) Securities Security: Beneficial
Beneficially Direct (D) Ownership
Owned at End or Indirect (I) (Instr. 4)
of Year (Instr. 4)
(Instr. 4)
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D
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Explanation of Responses:
* 200,000 are exercisable as of January 1, 2001
200,000 are exercisable as of January 1, 2002
200,000 are exercisable as of January 1, 2003
200,000 are exercisable as of January 1, 2004
200,000 are exercisable as of January 1, 2005
**Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ Lewis M. Edwards March 30, 2001
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.