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FORM 5 OMB APPROVAL
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OMB Number 3235-0362
Expires: December 31, 2001
[x] Check box if no U.S. SECURITIES AND EXCHANGE COMMISSION Estimated average burden
longer subject to WASHINGTON, D.C. 20549 hours per response ................ 1.0
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,
[ ] Form 3 Holdings Section 17(a) of the Public Utility
Reported Holding Company Act of 1935 or Section 30(f) of
[x] 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 to
ALLEN PAUL G. Shaman Pharmaceuticals, Inc. (SHMN) Issuer (Check all applicable)
------------------------------------------- ---------------------------------------------- Director x 10% Owner
(Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- ---
505 UNION STATION, 505 FIFTH AVENUE, Number of Reporting Month/Year Officer (give Other (specify
SUITE 990 Person (Voluntary) December 31, 2000 ---- title --- below)
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(Street) 5. If Amendment,
SEATTLE, WASHINGTON 98104 Date of Original -------------------------------
------------------------------------------- (Month/Year)
(City) (State) (Zip) 7. Individual or Joint/Group Filing
------------------ (Check applicable line)
Form Filed by one
---- Reporting Person
x 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 Month Direct Benefi-
(Month/ (Instr. 3 and 4) (D) or cial
Day/ ---------------------------- Indirect Owner-
Year) Amount (A) or Price (I) ship
(D) (Instr. 4) (Instr.
4)
Code
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Common Stock 2/1/2000 C4 3,418,153 A (1) 7,153,518(2) (I)(3) (3)
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Explanation of Responses:
(1) Automatically converted from Series R Preferred Stock on February 1, 2000.
(2) Includes 946,506 shares paid as a dividend on the Series C Stock on June 1, 2000 and 2,788,506 shares
paid as a dividend on the Series C Stock on November 30, 2000.
(3) Owned directly by Vulcan Ventures, Inc. ("VVI") and indirectly by Paul G. Allen, the sole shareholder of
VVI.
*If the form is filed by more than one Reporting Person, see Instruction 4(b)(v).
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
(Print or Type Responses)
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FORM 5 (CONTINUED) 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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Series R Preferred Stock 1:31 2/1/2000 C4 110,263 (1) Common Stock 3,418,153
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9. Number of 10. Ownership 11. Nature of
Derivative of Derivative Indirect
Securities Security Beneficial
Beneficially Direct (D) Ownership
Owned at End or Indirect (I) (Instr. 4)
of Month (Instr. 4)
(Instr. 4)
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-0- (1) (2)
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Explanation of Responses:
(1) Automatically converted on February 1, 2000.
(2) Owned directly by VVI and indirectly by Paul G. Allen, the sole shareholder of VVI
**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 D. SAVOY 2/14/2001
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**Signature of Reporting Person Date
William D. Savoy as Attorney-in Fact
for Paul G. Allen pursuant to a Power
of Attorney filed with the Reporting
Persons' Schedule 13G for Parthogenesis,
Inc. on August 30, 1999 and
incorporated herein by reference.
Note: File three copies of this Form, one of which must be manually signed.
If space provided is insufficient, see Instruction 6 for procedure.
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JOINT FILER INFORMATION
Name: Vulcan Ventures Incorporated
Address: 505-Fifth Avenue, Suite 900
Seattle, WA 98104
Designated Filer: Paul G. Allen
Issuer & Ticker Symbol: Shaman Pharmaceuticals, Inc. ("SHMN")
Date of Event
Requiring Statement: February 1, 2000
Signature: VULCAN VENTURES INCORPORATED
By: /s/ WILLIAM D. SAVOY 2/14/2001
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William D. Savoy, Vice President
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