U.S. SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, DC 20549
FORM 4
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
[_] Check this box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
(Print or Type Responses)
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1. Name and Address of Reporting Person*
Drill, Scott
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(Last) (First) (Middle)
5025 Cheshire Lane North
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(Street)
Plymouth, MN 55446
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Insignia Systems, Inc. (ISIG)
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
December 2001
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person to Issuer
(Check all applicable)
[X] Director [_] 10% Owner
[X] Officer (give title below) [_] Other (specify below)
President & CEO
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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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TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR
BENEFICIALLY OWNED
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6.
4. 5. Owner-
Securities Acquired (A) or Amount of ship
2. 3. Disposed of (D) Securities Form: 7.
Transaction Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of
Date Code ------------------------------- Owned at End (D) or Indirect
1. (Month/ (Instr. 8) (A) of Month Indirect Beneficial
Title of Security Day/ ------------ Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) Year) Code V (D) and 4) (Instr.4) (Instr. 4)
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Common Stock 12/27/01 G 6,500 D $8.13 42,171 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 Reporting Person, SEE Instruction
4(b)(v).
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.
(Over)
SEC 1474 (3-99)
FORM 4 (CONTINUED)
TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(e.g., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
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10.
9. Owner-
Number ship
of Form
2. Deriv- of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
or Derivative 6. of Underlying 8. ities Secur- of
Exer- 4. Securities Date Securities Price Bene- ity: In-
cise 3. Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- action or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Code of(D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date (Instr. (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ 8) 4 and 5) Date Expira- Number ity Month (I) ship
Security Secur- Day/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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EXPLANATION OF RESPONSES:
/s/ Scott Drill 1/4/02
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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 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.
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