UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL 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(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series A Convertible Preferred Stock (1) | Â (1) | Â (1) | Common Stock | 10,920,000 | $ 0 | I | See Footnote (1) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Ray John F 3353 PEACHTREE ROAD SUITE 1040 ATLANTA, GA 30326 |
 X |  X |  |  |
/s/ John F. Ray | 12/12/2005 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | The shares of Series A Convertible Preferred Stock are owned by Heritage Assurance Partners, L.P. ("HAP"), a Georgia limited partnership, (ii) Heritage Financial Partners, L.P. ("HFP"), a Georgia limited partnership, and (iii) Heritage Fund Advisors, LLC, a Georgia limited liability company registered as an investment advisor under the laws of the State of Georgia ("HFA"), the general partner of HAP and HFP. John F. Ray is the sole manager of HFA. Each share of Series A Convertible Preferred Stock is convertible into ten shares of common stock of AssuranceAmerica Corporation at the owners' option at any time , subject to adjustment in the event of stock splits, stock combinations and certain issuances of capital stock. |