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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 5
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
[_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
[_] Form 3 Holdings Reported
[x] Form 4 Transactions Reported
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1. Name and Address of Reporting Person*
Sample, Jr. John G.
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(Last) (First) (Middle)
4370 Peachtree Road, NE
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(Street)
Atlanta Georgia 30319-3000
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Atlantic American Corporation - AAME
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
________________________________________________________________________________
4. Statement for Month/Year
February, 2003
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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)
[_] Director [_] 10% Owner
[X] Officer (give title below) [ ] Other (specify below)
Senior Vice President and CFO
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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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5. 6.
4. Amount of Owner-
Securities Acquired (A) or Securities ship
Disposed of (D) Beneficially Form: 7.
(Instr. 3, 4 and 5) Owned at End Direct Nature of
2. 3. ----------------------------- of Issuer's (D) or Indirect
1. Transaction Transaction (A) Fiscal Year Indirect Beneficial
Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4)
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Common Stock 1,177 I 1
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Common Stock N/A 10,000 D 2
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* If the form is filed by more than one Reporting Person, see Instruction
4(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Over)
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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9. 10.
Number Owner-
of ship
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- Securities Date Securities Price Bene- ity: In-
cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship
Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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Employee Stock
Option 50,000 D 3
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Explanation of Responses:
1 401(k) Plan. Information herein is based on a plan statement as of
December 31, 2002.
2 Deferred Shares Award, granted under the Atlantic American Corporation 1992
Incentive Plan.
3 Options granted pursuant to the Company's 1992 Incentive Plan at an option
price of $2.00.
02/14/03
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John G. Sample, Jr. Date
**Signature of Reporting Person
** 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.
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