[DESCRIPTION]ANNUAL STATEMENT OF CHANGES
IN BENEFICIAL OWNERSHIP
FORM 5
/ / Check box if no longer OMB APPROVAL
subject to Section 16. OMB NUMBER: 3235-0362
Form 4 or Form 5 EXPIRES: SEPTEMBER 30, 1998
obligations may continue. ESTIMATED AVERAGE BURDEN
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See Instruction 1(b) HOURS PER RESPONSE 1.0
/X/ Form 3 Holdings Reported
/ / Form 4 Transactions Reported
U.S. 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(f) of the Investment Company Act of 1940
1. Name and Address of Reporting Person*
Tsai Aaron (Last) (First) (Middle) 1710 E. Division St. (Street) Evansville IN 47711 (City) (State) (Zip) |
2. Issuer Name and Ticker or Trading Symbol
MAS Acquisition XVII Corp.
(Common Stock: No Trading Symbol)
3. IRS or Social Security Number of Reporting Person (Voluntary)
4. Statement for Month/Year
12/99
5. If Amendment, Date of Original (Month/Year)
6. Relationship of Reporting Person(s) to Issuer (Check all applicable)
( V ) Director ( V ) 10% Owner
( V ) Officer (give title below) ( ) Other (specify below)
President, Chief Executive Officer and Treasurer
7. Individual or Joint/Group Filing (Check applicable line)
( V ) Form filed by One Reporting Person ( ) Form filed by More than One Reporting Person
* If Form is filed by more than one Reporting Person, see Instruction 4(b)(v).
(Print or Type Responses) Page 1
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security 2. Transaction Date
(Instr. 3) (Month/Day/Year)
- ------------------------------------- -----------------------
a. Common Stock, par value $.001
- ------------------------------------- -----------------------
b.
- ------------------------------------- -----------------------
c.
- ------------------------------------- -----------------------
d.
- ------------------------------------- -----------------------
e.
- ------------------------------------- -----------------------
f.
- ------------------------------------- -----------------------
3. Transaction 4. Securities Acquired (A) or
Code Disposed of (D)
(Instr. 8) (Instr. 3, 4 and 5)
-------------------------------------------
Amount (A) or (D) Price
- ----------------- ------------- ------------- -------------
a.
- ----------------- ------------- ------------- -------------
b.
- ----------------- ------------- ------------- -------------
c.
- ----------------- ------------- ------------- -------------
d.
- ----------------- ------------- ------------- -------------
e.
- ----------------- ------------- ------------- -------------
f.
- ----------------- ------------- ------------- -------------
5. Amount of Securities 6. Ownership Form: 7. Nature of Indirect
Benificially Owned Direct (D) or Beneficial Ownership
at End of Issuer's Fiscal Indirect (I) (Instr. 4)
Year (Instr. 4)
(Instr. 3 and 4)
- ----------------------------- ------------------ -----------------------
a. 8,250,350 I See explanation
- ----------------------------- ------------------ -----------------------
b.
- ----------------------------- ------------------ -----------------------
c.
- ----------------------------- ------------------ -----------------------
d.
- ----------------------------- ------------------ -----------------------
e.
- ----------------------------- ------------------ -----------------------
f.
- ----------------------------- ------------------ -----------------------
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
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(Print or Type Responses) Page 2
Table II - Derivative Securities Acquired, Disposed of, or
Beneficially Owned
(e.g, puts, calls, warrants, options, convertible securities)
1. Title of 2. Conver- 3. Transac- 4. Transac- 5. Number of
Derative sion or sion sion Derivative
Security Exercise Date Code Securities
(Instr. 3) Price (Month/ Acquired (A) or
of Day/ (Instr. 8) Disposed of (D)
Derivative Year) (Instr. 3, 4 and 5)
Security --------------------
(A) (D)
- ------------ -------------- ---------- ------------- --------- ----------
a.
- ------------ -------------- ---------- ------------- --------- ----------
b.
- ------------ -------------- ---------- ------------- --------- ----------
c.
- ------------ -------------- ---------- ------------- --------- ----------
d.
- ------------ -------------- ---------- ------------- --------- ----------
e.
- ------------ -------------- ---------- ------------- --------- ----------
f.
- ------------ -------------- ---------- ------------- --------- ----------
6. Date Exercisable 7. Title and Amount of Underlying 8. Price of
and Expiration Securities Derivative
Date (Instr. 3 and 4) Security
(Month/Day/Year) (Instr. 5)
- --------------------------- ---------------------------------
Date Expiration Title Amount or
Exercisable Date Number of
Shares
- --------------- ----------- ----------------- -------------- -------------
a.
- --------------- ----------- ----------------- -------------- -------------
b.
- --------------- ----------- ----------------- -------------- -------------
c.
- --------------- ----------- ----------------- -------------- -------------
d.
- --------------- ----------- ----------------- -------------- -------------
e.
- --------------- ----------- ----------------- -------------- -------------
f.
- --------------- ----------- ----------------- -------------- -------------
9. Number of 10. Ownership 11. Nature of
Derivative of Deriva- Indirect
Securities tive Beneficial
Beneficially Security: Ownership
Owned at Direct (D) (Instr. 4)
End of Year or Indirect
(Instr. 4) (I) (Instr. 4)
------------------- -------------------- -----------------
a.
------------------- -------------------- -----------------
b.
------------------- -------------------- -----------------
c.
------------------- -------------------- -----------------
d.
------------------- -------------------- -----------------
e.
------------------- -------------------- -----------------
f.
------------------- -------------------- -----------------
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Explanation of Responses:
(1) MAS Capital Inc. is controlled by Aaron Tsai. 8,250,000 shares are owned by MAS Capital Inc. and 350 shares are owned by John Tsai, brother of Aaron Tsai.
/s/ Aaron Tsai January 31, 2000 - ------------------------------- ---------------------- ** 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.
(Print or Type Responses) Page 3