OMB APPROVAL ------------------------------ OMB Number: 3235-0104 Expires: September 30, 1998 Estimated average burden hours per response ....... 0.5 ------------------------------ U.S. SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 3 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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 (Print or Type Responses) ________________________________________________________________________________ 1. Name and Address of Reporting Person* Kolls Haven B - -------------------------------------------------------------------------------- (Last) (First) (Middle) 1573 Potter Drive - -------------------------------------------------------------------------------- (Street) Pottstown PA 19464 - -------------------------------------------------------------------------------- (City) (State) (Zip) 10/28/02 ________________________________________________________________________________ 2. Date of Event Requiring Statement (Month/Day/Year) ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) USA Technologies (USTT) ________________________________________________________________________________ 4. Issuer Name and Ticker or Trading Symbol ________________________________________________________________________________ 5. Relationship of Reporting Person to Issuer (Check all applicable) [ ] Director [ ] 10% Owner [X] Officer (give title below) [ ] Other (specify below) Sr. Vice President R & D ________________________________________________________________________________ 6. If Amendment, Date of Original (Month/Day/Year) ________________________________________________________________________________ 7. Individual or Joint/Group Filing (Check applicable line) [X] Form Filed by One Reporting Person [ ] Form Filed by More than One Reporting Person ================================================================================ Table I -- Non-Derivative Securities Beneficially Owned ================================================================================ * If the Form is filed by more than one Reporting Person, see Instruction 5(b)(v). Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over) SEC 1473(7/96)
3. Ownership Form: 2. Amount of Securities Direct (D) or 1. Title of Security Beneficially Owned Indirect (I) 4. Nature of Indirect Beneficial Ownership (Instr. 4) (Instr. 4) (Instr. 5) (Instr. 4) - ---------------------------------------------------------------------------------------------------------------------------------- Common Stock 41,725 D Common Stock 16,500 I Wife Total Common Stock 58,225 - ----------------------------------------------------------------------------------------------------------------------------------- FORM 3 (continued) Table II -- Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) Explanation of Responses: By: /s/ Haven B. Kolls 01/03/02 ---------------------- --------------- Haven B. Kolls 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. 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
=================================================================================================================================== 5. Owner- 3. Title and Amount of Securities ship Underlying Derivative Security Form of 2. Date Exercisable (Instr. 4) Derivative and Expiration Date --------------------------------- 4. Conver- Security: (Month/Day/Year) Amount sion or Direct 6. Nature of ---------------------- or Exercise (D) or Indirect Date Expira- Number Price of Indirect Beneficial 1. Title of Derivative Exer- tion of Derivative (I) Ownership Security (Instr. 4) cisable Date Title Shares Security (Instr. 5) (Instr.5) - ----------------------------------------------------------------------------------------------------------------------------------- Preferred Stock Series A Warrants Options 08/15/94 06/30/03 Common Stock 5,000 2.50 D Options 03/15/95 06/30/03 Common Stock 10,000 1.50 D Options 03/15/96 06/30/03 Common Stock 5,000 2.50 D Options 03/15/96 06/30/03 Common Stock 5,000 4.50 D Options 06/08/98 06/30/03 Common Stock 10,000 4.50 D Options 04/13/99 06/30/03 Common Stock 5,000 4.50 D Options 06/17/99 06/17/04 Common Stock 33,334 2.00 D Options 06/17/00 06/17/05 Common Stock 33,333 2.00 D Options 06/17/01 06/17/06 Common Stock 33,333 2.00 D Options 11/23/99 11/23/04 Common Stock 30,000 2.00 D Options 08/26/01 08/26/06 Common Stock 26,667 1.00 D Options 05/26/02 05/26/07 Common Stock 26,667 1.00 D Options 04/12/02 04/12/05 Common Stock 50,000 0.40 D Options Total 273,334 2000-C Senior Note 12/31/03 Common Stock 24,000 1.25 I Spouse Convertible Note 24,000 Total: 355,559 ===================================================================================================================================