---------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION -------------------------------
FORM 5 WASHINGTON, DC 20549 OMB APPROVAL
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ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OMB NUMBER:
[ ] Check box if no longer EXPIRES:
subject to Section 16. Filed pursuant to Section 16(a) of the Securities ESTIMATED AVERAGE BURDEN
Form 4 or Form 5 Exchange Act of 1934, Section 17(a) of the HOURS PER RESPONSE.........1.0
obligations may continue. Public Utility Holding Company Act of 1935 --------------------------------
See Instruction 1(b). or Section 30(f) of the
[ ] Form 3 Holdings Reported Investment Company Act of 1940
[X] Form 4 Transactions
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(s)
to Issuer (Check all applicable)
Bindseil Mark Billserv, Inc. BLLS
--------------------------------------------- ---------------------------------------------- Director 10% Owner
(Last) (First) (Middle) 3. IRS Identification 4. Statement for --- ---
Number of Reporting Month/Year
211 N. Loop 1604 East, Suite 100 Person, if an entity X Officer Other
--------------------------------------------- (Voluntary) October 2001 --- (give title --- (Specify title
(Street) ------------------- below) below)
5. If Amendment, VP, Controller
San Antonio TX 78232 -------------------- Date of -------------------------------
--------------------------------------------- Original 7. Individual or Joint/Group Reporting
(City) (State) (Zip) (Month/Year) (Check Applicable Line)
X Form filed by One Reporting
--- Person
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. Trans- 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature of
(Instr. 3) action action or Disposed of (D) Securities Form: Indirect
Date Code (Instr. 3, 4 and 5) Beneficially Direct (D) Beneficial
(Instr. 8) Owned at End or Ownership
(Month/ ----------------------- of Fiscal Year Indirect (I) (Instr. 4)
Day/ (A) or (Instr. 3 and 4) (Instr. 4)
Year) Amount (D) Price
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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)
*If the Form is filed by more than one Reporting Person, see Instruction 4(b)(v). SEC 2270 (7-97)
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. Transaction 5. Number of 6. Date Exer- 7. Title and 8. Price of
Security sion or action Code Derivative cisable and Amount of Derivative
(Instr. 3) Exercise Date (Instr. 8) Securities Expiration Underlying Security
Price of (Month/ Acquired (A) Date Securities (Instr. 5)
Derivative Day/ or Disposed of (Month/Day/ (Instr.
Security Year) (D) (Instr. 3, Year) 3 and 4)
4, and 5) ---------------- -----------------
Date Expira- Amount or
---------------- Exer- tion Number of
(A) (D) cisable Date Title Shares
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Stock Option $.86 10/31/01 A4 27,000 (1) 10/31/11 Common 27,000
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1. Title of Derivative 9. Number of 10. Ownership of 11. Nature of
Security Derivative Derivative Indirect
(Instr. 3) Securities Security: Beneficial
Beneficially Direct (D) Ownership
Owned at End or Indirect (I) (Instr. 4)
of Year (Instr. 4)
(Instr. 4)
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Stock Option 48,000 D
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Explanation of Responses:
(1) 9,000 shares on 10/31/02, 10/31/03, 10/31/04
**Intentional misstatements or omissions of facts constitute Federal Criminal
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). -------------------------- -----------------
**Signature of Date
Reporting Person
Note: File three copies of this Form, one of which must be manually signed. Page 2
If space provided is insufficient, see Instruction 6 for procedure. SEC 2270 (7-97)
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.