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FORM 5
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OMB APPROVAL
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[ ] CHECK THIS BOX IF NO LONGER OMB Number: 3235-0362
SUBJECT TO SECTION 16. FORM 4 OR FORM Expires: October 31, 2001
5 OBLIGATIONS MAY CONTINUE. SEE Estimated average burden
INSTRUCTION 1(b). hours per response ........ 1.0
[ ] FORM 3 HOLDINGS REPORTED
[X] FORM 4 TRANSACTIONS REPORTED U.S. SECURITIES AND EXCHANGE COMMISSION
(Print or Type Responses) 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(f) of the Investment Company Act of 1940
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1.Name and Address of Reporting Person*(1) 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting
Person to Issuer
Caballero, Jose Latin American Casinos, Inc., "LACI" (Check all applicable)
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(Last) (First) (Middle) 3. IRS or Social 4. Statement for Month/Year [X] Director [ ] 10% Owner
Security Number [ ] Officer [ ] Other
of Reporting 2000 (give title (specify
2000 NE 164th Street Person below) below)
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(Street)
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North Miami Beach, Florida 33162 5. If Amendment, 7. Individual or Joint/Group Filing
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(City) (State) (Zip) (Month/Year)
[X] Form filed by One Reporting Person
[ ] Form filed by More than One Reporting Person
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TABLE I - NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Ownership Form: 7. Nature of
(Instr.3) action action Code or Disposed of (D) Securities Direct (D) or Indirect
Date (Instr. 8) (Instr. 3,4 and 5) Beneficially Indirect (I) Beneficial
Owned at End of (Instr. 4) Ownership
(Month/ Issuer's (Instr. 4)
Day/Year)------------------------------------------------- Fiscal Year
Code V Amount (A) or (D) Price (Instr. 3 and 4)
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(OVER)
*If the form is filed by more than one reporting person, SEE Instruction 4(b)(v). SEC 2270(3/99)
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 CONTROL NUMBER.
Page 1 of 2
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 2. Conversion 3. Transaction 4. Transaction 5. Number of
Derivative or Exercise Date Code Derivative
Security Price of (Month/Day/Year) (Instr. 8) Securities
(Instr. 3) Derivative Acquired (A)
Security or Disposed
of (D)
(Instr. 3, 4
and 5)
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(A) (D)
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Option $1.75 10/3/2000 A4 25,000
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6. Date 7. Title and Amount 8. Price of 9. Number of 10. Ownership 11. Nature of
Exercisable of Underlying Derivative Derivative Form of Indirect
and Expiration Securities Security Securities Derivative Beneficial
Date (Instr. 3 and 4) (Instr. 5) Beneficially Security: Ownership
(Month/Day/Year) Owned at Direct (D) or (Instr. 4)
End of Indirect (I)
Year (Instr. 4)
(Instr. 4)
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Amount
Date Expir- or
Exer- ation Number
cisable Date Title of Shares
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Common (See explana-
10/3/2000 10/2/2010 Stock 25,000 tion below) 30,000 D
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Explanation of Responses:
Options issued by Latin American Casinos, Inc. to the Reporting Person in
consideration for the Reporting Person serving on the Board of Directors.
** 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.
By: Jose Caballero
/s/ JOSE CABALLERO February 14, 2001
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**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.
Page 2 of 2
SEC 2270 (7-97)