FORM 4
U.S. SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, DC 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Check box if no longer subject to | ||
Section 16. Form 4 or Form 5 obligations may | ||
continue. See Instruction 1(b). |
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
1. Name and Address of Reporting Person* | 2. Issuer Name and Ticker or Trading Symbol | 6. Relationship of Reporting Person | |||
Koch David A. | SurModics, Inc. (SRDX) | to Issuer (Check all applicable) | |||
(Last) (First) (Middle) |
Director 10% Owner | ||||
Officer (give title below) | |||||
3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) | Other (specify below) | ||||
1582A Homestead Trail | |||||
(Street) |
|||||
4. Statement for Month/Year | 7. Individual or Joint/Group Filing | ||||
Long Lake MN 55356 | May 2002 | (Check applicable line) | |||
(City) (State) (Zip) |
Form Filed by One Reporting Person | ||||
Form Filed by More than One Reporting Person |
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5. If Amendment, Date of Original (Month/Year) | |||||
TABLE I NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
4. Securities Acquired (A) | ||||||||||||
3. Transaction Code | or Disposed of (D) | |||||||||||
2. Transaction Date | (Instr. 8) | (Instr. 3, 4 and 5) | ||||||||||
(A) | ||||||||||||
or | ||||||||||||
1. Title of Security (Instr. 3) | (Month/Day/Year) | Code | V | Amount | (D) | Price | ||||||
Common Stock | 5/30/02 | G | V | 50 | D | None | ||||||
Common Stock | ||||||||||||
[Additional columns below]
[Continued from above table]
5. Amount of | 6. Ownership Form: | |||
Securities Beneficially | Direct (D) or | 7. Nature of Indirect | ||
Owned at End of Month | Indirect (I) | Beneficial Ownership | ||
(Instr. 3 and 4) | (Instr. 4) | (Instr. 4) | ||
764,510 | D | |||
142,000 | I | Trust (1) | ||
FORM 4 (CONTINUED)
TABLE II DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
5. Number of | |||||||||||||||||
Derivative | |||||||||||||||||
Securities | |||||||||||||||||
Acquired (A) or | |||||||||||||||||
4. Transaction | Disposed of (D) | ||||||||||||||||
Code | (Instr. 3, 4, | ||||||||||||||||
2. Conversion or | (Instr. 8) | and 5) | |||||||||||||||
1. Title of Derivative | Exercise Price of | 3. Transaction Date | |||||||||||||||
Security (Instr. 3) | Derivative Security | (Month/Day/Year) | Code | V | (A) | (D) | |||||||||||
Director Stock Option (Right to Buy) | $ | 6.563 | Previously Reported | ||||||||||||||
Director Stock Option (Right to Buy) | $ | 2.50 | Previously Reported | ||||||||||||||
Director Stock Option (Right to Buy) | $ | 25.094 | Previously Reported | ||||||||||||||
Director Stock Option (Right to Buy) | $ | 34.85 | 11/12/01 | A | V | 1,000 |
[Additional columns below]
[Continued from above table]
6. Date Exercisable | 7. Title and Amount | ||||||||
and Expiration | of Underlying | ||||||||
Date (Month/Day/ | Securities | ||||||||
Year) | (Instr. 3 and 4) | ||||||||
8. Price of | |||||||||
Amount or | Derivative | ||||||||
Date | Expiration | Number of | Security | ||||||
Exercisable | Date | Title | Shares | (Instr. 5) | |||||
(2) | 5/17/09 | Common Stock | 9,000 | None | |||||
(3) | 9/18/05 | Common Stock | 40,000 | None | |||||
(4) | 9/18/10 | Common Stock | 2,000 | None | |||||
(5) | 11/12/11 | Common Stock | 1,000 | None |
9. Number of | 10. Ownership | |||
Derivative | Form of | |||
Securities | Derivative | 11. Nature of | ||
Beneficially | Securities | Indirect | ||
Owned at End | Beneficially | Beneficial | ||
of Month | owned at end of month | Ownership | ||
(Instr. 4) | (Instr. 4) | (Instr. 4) | ||
9,000 | D | |||
40,000 | D | |||
2,000 | D | |||
1,000 | D |
Explanation of Responses:
(1) | These shares are owned by a trust established under the will of Clarissa L. Gray. The wife and children of David A. Koch are among the beneficiaries of the trust. The trustees of the trust are David A. Koch, Paul M. Torgerson and U.S. Bank Trust National Association SD. | |
(2) | Exercisable in annual increments of 1,800 shares each commencing 5/17/99. | |
(3) | Exercisable in annual increments of 8,000 shares each commencing 9/18/95. | |
(4) | Exercisable in annual increments of 400 shares each commencing 9/18/00. | |
(5) | Exercisable in annual increments of 299 shares each commencing 11/21/01. |
/s/ David A.
Koch |
July 3, 2002 |
|
**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 is insufficient, see Instruction 6 for procedure.
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(Print or Type Responses)