SEC FORM
4
SEC Form 4
| FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
|
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3235-0287 |
| Expires: |
December 31, 2014 |
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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*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
MERIT MEDICAL SYSTEMS INC
[ MMSI ]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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3. Date of Earliest Transaction
(Month/Day/Year)
06/30/2003
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4. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. 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 |
|---|
| 1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
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4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
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5.
Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr.
3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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7. Nature of Indirect Beneficial Ownership (Instr.
4)
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| Code |
V |
Amount |
(A) or (D) |
Price |
| Common stock, no par value |
06/27/2003 |
06/27/2003 |
M |
|
10,156 |
A |
3.76 |
45,719 |
D |
|
| Common stock, no par value |
06/27/2003 |
06/27/2003 |
S |
|
10,156 |
D |
20.2485 |
37,126 |
D |
|
| Common stock, no par value |
06/30/2003 |
06/30/2003 |
M |
|
11,719 |
A |
2.88 |
47,282 |
D |
|
| Common stock, no par value |
06/30/2003 |
06/30/2003 |
S |
|
11,719 |
D |
20.0021 |
35,563 |
D |
|
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction Code (Instr.
8)
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5.
Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr.
3, 4 and 5)
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6. Date Exercisable and Expiration Date
(Month/Day/Year) |
7. Title and Amount of Securities Underlying Derivative Security (Instr.
3 and 4)
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8. Price of Derivative Security (Instr.
5)
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9.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
4)
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10. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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11. Nature of Indirect Beneficial Ownership (Instr.
4)
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| Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
|
James J. Ellis per Kent Stanger, Atty in fact per pwr of atty dtd 11/25/95, on file, incorporated |
07/01/2003 |
|
** Signature of Reporting Person |
Date |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
| * If the form is filed by more than one reporting person,
see
Instruction
4
(b)(v). |
| ** 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 is insufficient,
see
Instruction 6 for procedure. |
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |
EXHIBIT 99.1 - Derivative Securities - James Ellis 06/30/03 FORM 4 (continued)
================================================================================
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
================================================================================
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)
=============================================================================================================================
Non-qual $3.76 06/27/03 M 10,156 05/26/99 05/26/04 Common 10,156 0 D
stock Stock
options
Right to Buy
- -----------------------------------------------------------------------------------------------------------------------------
Non-qual $2.88 06/30/03 M 11,719 05/24/00 05/24/05 Common 11,719 0 D
stock Stock
options
Right to Buy
- -----------------------------------------------------------------------------------------------------------------------------
Non-qual $5.0624 N/A 05/23/01 05/23/11 Common 15,625 D
stock Stock
options
Right to Buy
- -----------------------------------------------------------------------------------------------------------------------------
Non-qual $16.99 N/A 05/23/02 05/23/12 Common 10,000 D
stock Stock
options
Right to Buy
- -----------------------------------------------------------------------------------------------------------------------------
Non-qual $18.62 05/22/03 A 15,000 05/22/03 05/22/13 Common 15,000 15,000 D
stock Stock
options
Right to Buy
=============================================================================================================================
Explanation of Responses:
/s/ JAMES J. ELLIS 07/01/03
- ----------------------------------- -----------
**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.
