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FORM 3 OMB APPROVAL
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OMB Number: 3235-0104
Expires: October 31, 2001
Estimated average burden
hours per response . . . . . 0.5
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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
(PRINT OR TYPE RESPONSES)
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1. Name and Address of Reporting Person
Blaskiewicz William A.
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(Last) (First) (Middle)
c/o OptiCare Health Systems, Inc.
87 Grandview Avenue
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(Street)
Waterbury CT 06708
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(City) (State) (Zip)
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2. Date of Event Requiring Statement (Month/Day/Year)
February 2, 2000
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Issuer Name and Ticker of Trading Symbol
OptiCare Health Systems, Inc. (OPT)
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5. Relationship of Reporting Person to Issuer
(Check all applicable)
[ ] Director
[ ] 10% Owner
[X] Officer (give title below)
[ ] Other (specify below)
Chief Accounting Officer
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6. If Amendment, Date of Original (Month/Day/Year)
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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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FORM 3 (CONTINUED)
TABLE I--NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
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1. Title of Security 2. Amount of Securities 3. Ownership 4. Nature of Indirect Beneficial Ownership
(Instr. 4) Beneficially Owned Form: Direct (Instr. 5)
(Instr. 4) (D) or Indirect
(I) (Instr. 5)
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Common Stock, $0.001
par value per share 1,787 D
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Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
* If the form is filed by more than one person, See Instruction 5(b)(v).
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 2. Date Exer- 3. Title and Amount of Securities 4. Conver- 5. Owner- 6. Nature of
Security (Instr. 4) cisable and Underlying Derivative Security sion or ship Indirect
Expiration (Instr. 4) Exercise Form of Beneficial
Date Price of Deriv- Ownership
(Month/Day/Year) Deriv- ative (Instr. 5)
ative Security:
Security Direct
(D) or
Indirect
(I)
(Instr. 5)
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Amount or
Date Expira- Title Number
Exer- tion of
cisable Date Shares
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Stock Options
(Right to Buy) (1) 8/13/09 Common Stock 10,000 $5.85 D
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Stock Options
(Right to Buy) (2) 1/4/08 Common Stock 5,868 $2.56 D
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(1) Exercisable in four equal annual installments beginning on August 13, 2000.
(2) Exercisable in four equal annual installments beginning on January 4, 1999.
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
* If the Form is filed by more than one reporting person, See
Instruction 5(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).
/s/ William Blaskiewicz 2/10/01
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** Signature of Reporting Person Date
Note: File three copies of this Form, one of which must be manually signed.
If space 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.
(Over)
SEC 1473 (7/96)