FORM 4 |
Check this box if no longer
subject to Section 16.
Form 4 or Form 5
obligations may continue.
See Instruction 1(b).
1. Name and Address of Reporting Person
Richard D. Surber |
2. Issuer Name and Ticker or Trading Symbol
Kelly's Coffee Group, Inc. OTC-Bulletin Board Symbol =KLYS
|
6. Relationship of Reporting Person to Issuer
X Director X 10% Owner X Officer (give title below) Other (specify below)
Surber is President and Director of the Issuer.
| |
(Last) (First) (Middle)
268 West 400 South - Suite 300 |
3. IRS or Social Security Number of Reporting Person (Voluntary) |
4. Statement for Month/Year February, 2002 |
|
(Street)
Salt Lake City Utah 84101 |
5. If Amendment,
Date of Original (Month/Year) |
||
(City) (State) (Zip) |
1. Title of Security
(Instr. 3) |
2. Transaction Date
(Month/Day/Year) |
3. Transaction
Code (Instr. 8) |
4. Securities Acquired (A) or Disposed of
(D)
(Instr. 3, 4 and 5) |
5. Amount of
Securities
Beneficially Owned
at End of Month
(Instr. 3 and 4) |
6.
Ownership
Form:
Direct (D) or Indirect (I) (Instr. 4) |
7. Nature of
Indirect Beneficial
Ownership
(Instr. 4) | |||
Code |
V |
Amount |
(A) or
(D) |
Price |
|||||
Common Stock | February 19, 2002 | P | V | 225,100,000 | A | $0.018 | 239,292,540 | D& I | President of Axia Group, Inc. |
FORM 4 (continued)
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security |
3. Transaction Date (Month/ Day/Year) |
4. Trans-action Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4,& 5) |
6. Date Exercisable and Expiration Date (Month/ Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Deriv-ative Security (Instr.5) |
9. Number of Derivative Securities Beneficially Owned at End of Month (Instr. 4) |
10.Owner-ship Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature
of
Indirect
Beneficial Owner-ship (Instr. 4) | ||||
|
V |
|
|
Date Exer-cisable |
Expir-ation Date |
|
Amt.. or No. of Shares |
|||||||
Explanation of Responses: 239,292,540 shares are beneficially attributed to Mr. Surber as President of Axia Group, Inc. which directly owns 225,705,000 shares and indirectly owns 7,038,340 shares through subsidiaries. As a result of the purchase of shares of Kellys Coffee Group, Inc. described herein, Kellys Coffee Group, Inc. became a majority owned subsidiary of Axia Group, Inc. As part of the transaction, Kellys acquired as subsidiaries, Hudson Consulting Group, Inc., which owns 3,904,720 shares of Kellys Coffee Group, Inc. and Oasis International Hotel & Casino, Inc. which ownes 3,133,620 shares of Kellys Coffee Group, Inc.
** Intention misstatements or omission of facts constitute Federal Criminal Violations.
Date: February 20, 2001
/s/ Richard D. Surber
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.
Page 2
SEC 1474 (8-92)