------------------------------
OMB APPROVAL
------------------------------
OMB Number 3235-0287
Expires: December 31, 2001
Estimated average burden
Hours per response ....... 0.5
------------------------------
U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 4
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
[X] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
See Footnote 2 Below
(Print or Type Responses)
--------------------------------------------------------------------------------
1. Name and Address of Reporting Person*
Andersen G. Chris
--------------------------------------------------------------------------------
(Last) (First) (Middle)
1330 Avenue of the Americas, 36th Floor
--------------------------------------------------------------------------------
(Street)
New York New York 10036
--------------------------------------------------------------------------------
(City) (State) (Zip)
--------------------------------------------------------------------------------
2. Issuer Name and Ticker or Trading Symbol
Park City Group, Inc.-- PKCY
--------------------------------------------------------------------------------
3. IRS or Social Security Number of Reporting Person (Voluntary)
N/A
--------------------------------------------------------------------------------
4. Statement for Month/Year
August 2002
--------------------------------------------------------------------------------
5. If Amendment, Date of Original (Month/Year)
--------------------------------------------------------------------------------
6. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
[_] Director [X] 10% Owner
[_] Officer (give title below) [_] Other (specify below)
________________________________________________________________________________
7. Individual or Joint/Group Filing (Check applicable line)
[X] Form filed by one Reporting Person
[_] Form filed by more than one Reporting Person
________________________________________________________________________________
================================================================================
Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
================================================================================
6.
4. 5. Owner-
Securities Acquired (A) or Amount of ship
3. Disposed of (D) Securities Form: 7.
Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of
2. Code ------------------------------- Owned at End (D) or Indirect
1. Transaction (Instr. 8) (A) of Month Indirect Beneficial
Title of Security Date ------------ Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) Code V (D) and 4) (Instr.4) (Instr. 4)
------------------------------------------------------------------------------------------------------------------------------------
Common Stock 08/16/2002 J(1) (1) (1) (1) (1) (I) (2)
====================================================================================================================================
(Over)
(Form 4-07/98)
FORM 4 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
================================================================================
10.
9. Owner-
Number ship
of Form
2. Deriv- of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
or Derivative 6. of Underlying 8. ities Secur- of
Exer- 4. Securities Date Securities Price Bene- ity: In-
cise 3. Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- action or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Code of(D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date (Instr. (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ 8) 4 and 5) Date Expira- Number ity Month (I) ship
Security Secur- Day/ ------- ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4)
------------------------------------------------------------------------------------------------------------------------------------
Warrant to $0.10 8/16/02 J(1) (1) (1) 6/11/02 3/27/05 Common (1) (1) (1) (I) (2)
Purchase Stock
Common Stock
====================================================================================================================================
Explanation of Responses:
(1) Pursuant to Section 5.4 of the Securities Purchase Agreement dated March 27,
2002 between AW Fields Acquisition, LLC ("AW Fields") (see note (2) below) and
the Issuer (the "SPA"), on August 16, 2002, the Issuer issued to AW Fields
8,458,334 shares of Common Stock, increasing the number of shares of Common
Stock beneficially owned by AW Fields (excluding shares issuable upon exercise
of the Warrant referred to below) from 11,666,667 to 20,125,001, and, pursuant
to Sections 2 and 9 of the Warrant to Purchase Common Stock (the "Warrant")
issued by the Issuer to AW Fields on June 11, 2002 pursuant to the SPA, the
exercise price at which the Warrant may be exercised was reduced from $0.1725 to
$0.10, and the number of shares issuable upon exercise of the Warrant increased
from 11,666,667 to 20,125,001.
(2) AW Fields is the direct beneficial owner of the 20,125,001 shares of Common
Stock and the Warrant to purchase the additional 20,125,001 shares of Common
Stock for $0.10 a share. The management of AW Fields is vested in its Class 1
Member, AWEE II, LLC ("AWEE"); the management of AWEE is vested in its Class 1
Member, Andersen, Weinroth & Co., L.P. ("AW"); and the management of AW is
vested in its general partner, A.W. & Co. GP Inc., which is wholly-owned by the
Reporting Person and Stephen D. Weinroth. Accordingly, for purposes of Rule
16a-1(a)(1), each of the Reporting Person and Stephen D. Weinroth may be deemed
the beneficial owner of the shares of Common Stock beneficially owned by AW
Fields.
As the Class 1 Member of AW Fields, AWEE is entitled to 20% of all distributions
of cash and other property by AW Fields, after the other members of AW Fields
have received cash and other property from AW Fields having an aggregate fair
value equal to $1,750,000 plus an amount in the nature of interest on
$1,750,000, compounded semiannually, at the rate of 10% a year. At present, AW
is entitled to all cash and other property distributions AWEE receives from AW
Fields. For purposes of Rule 16a-1(a)(2), the Reporting Person, through his
interest in AW, may be deemed to have an indirect pecuniary interest in such
cash and other property distributions.
* If the Form is filed by more than one Reporting Person, see Instruction
4(b)(v).
** 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.
/s/ G. Chris Andersen 09/10/02
--------------------------------------------- -----------------------
Signature of Reporting Person Date
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.