5 1 a2100305z5.htm 5

        FORM 5

o Check box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
o Form 3 Holdings Reported
o Form 4 Transactions Reported
  UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

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(h) of the Investment Company Act of 1940
 
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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) to Issuer
(Check all applicable)
    NOVELLY   PAUL   A.       BOSS HOLDINGS, INC.    (BSHI)           X     Director                  10% Owner

 
           
    (Last)   (First)   (Middle)   3.   I.R.S Identification Number of Reporting Person, if an entity (voluntary)   4.   Statement for Month/Year                    Officer
              (give title below)
               Other
              (specify below)
    8235 FORSYTH BLVD., SUITE 400               JANUARY, 2003            

 
 
     
(Street)           5.   If Amendment, Date of Original (Month/Year)   7.   Individual or Joint/Group Reporting
(check applicable line)
    X     Form Filed by One Reporting Person
             Form Filed by More than
    ST. LOUIS   MO   63105                                   One Reporting Person

    (City)   (State)   (Zip)                            
                Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

1.   Title of Security
(Instr. 3)
  2.   Transaction Date
(Month/ Day/ Year)
  2A.   Deemed Execution Date, if any
(Month/ Day/ Year)
  3.   Transaction Code
(Instr. 8)
  4.   Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
  5.   Amount of Securities Beneficially Owned at the end of Issuer's Fiscal Year   6.   Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
  7.   Nature of Indirect Beneficial Ownership
(Instr. 4)
                               
      (Instr. 3 and 4)                
                                        Amount   (A) or (D)   Price                        

    COMMON STOCK                                                                                                -0-       See Note 1                 

                                                                                           

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

*If the form is filed by more than one reporting person, see Instruction 4(b)(v).


FORM 5 (Continued)   Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned
(
e.g., puts, calls, warrants, options, convertible securities)

1.   Title of Derivative Security
(Instr. 3)
  2.   Conversion or Exercise Price of Derivative Security   3.   Transaction Date
(Month/Day/Year)
  3A.   Deemed Execution Date, if any
(Month/Day/Year)
  4.   Transaction Code
(Instr. 8)
  5.   Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4, and 5)
  6.   Date Exercisable and Expiration Date (Month/Day/Year)
                                           
     
                                                (A)   (D)       Date Exercisable   Expiration Date

    Non-Employee Director Options       $1.90       3/27/02               A           10,000           See Note 2   3/26/12

                                                                 

    Non-Employee Director Options       $1.75                                               12/31/99   3/08/09

                                                                 

                                                                 

                                                                 

                                                                 

                                                                 


                                                               

7.   Title and Amount of Underlying Securities
(Instr. 3 and 4)
  8.   Price of Derivative Security
(Instr. 5)
  9.   Number of Derivative Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 4)
  10.   Ownership Form of Derivative Securities: Direct (D) or Indirect (I) (Instr. 4)   11.   Nature of Indirect Beneficial Ownership
(Instr. 4)
   
                               
    Title   Amount or Number of Shares                                

    Common Stock   10,000       N/A       10,000       D        

                                         

    Common Stock   12,000               12,000       D        

                                         

                                         

                                         

                                         

                                         

                                       

Explanation of Responses:

1.
Does not include 87,283 shares of common stock owned by Novelly Exempt Trust U/I dtd. 8/12/92, an irrevocable trust established by Mr. Novelly, but as to which he is not a trustee and does not have the right to name or replace the trustee. Mr. Novelly disclaims beneficial ownership of the shares owned by Novelly Exempt Trust.

2.
Options exercisable as to 3,333, 3,333 and 3,334 shares each beginning May 1, 2003, 2004 and 2005, respectively.

/s/ PAUL A. NOVELLY   1/10/2003

**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.

http://www.sec.gov/divisions/corpfin/forms/form5.htm
Last update: 09/03/2002