SEC FORM
5/A
SEC Form 5
| FORM 5 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL 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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| OMB APPROVAL |
| OMB Number: |
3235-0362 |
| Estimated average burden |
| hours per response: |
1.0 |
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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). |
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Form 3 Holdings Reported. |
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Form 4 Transactions Reported. |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
SURMODICS INC
[ SRDX ]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| Senior Vice President |
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3. Statement for Issuer's Fiscal Year Ended
(Month/Day/Year)
09/30/2003
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4. If Amendment, Date of Original Filed
(Month/Day/Year)
11/14/2003
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
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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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| 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 at end of Issuer's Fiscal Year (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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| Amount |
(A) or (D) |
Price |
| Common Stock |
10/03/2002 |
|
G |
1,000 |
D |
$0
|
220,479
|
D |
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| Common Stock |
04/14/2003 |
|
G |
1,000 |
D |
$0
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219,479
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D |
|
| Common Stock |
06/03/2003 |
|
G |
1,000 |
D |
$0
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218,479
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D |
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| Common Stock |
07/31/2003 |
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G |
1,000 |
D |
$0
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217,479
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D |
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| Common Stock |
|
|
|
|
|
|
132,000 |
I |
By Spouse |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 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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| (A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Employee Stock Option (Right to Buy) |
$3.875
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|
|
|
|
|
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09/21/2005 |
Common Stock |
10,000 |
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10,000 |
D |
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| Employee Stock Option (Right to Buy) |
$29.17
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|
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|
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03/17/2010 |
Common Stock |
10,000 |
|
10,000 |
D |
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| Explanation of Responses: |
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| Remarks: |
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Philip D. Ankeny as Attorney-In-Fact for Patrick E. Guire pursuant to Power of Attorney attached hereto |
12/05/2003 |
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** 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. |
POWER OF ATTORNEY
The undersigned hereby constitutes and appoints Philip D. Ankeny,
David C. Grorud and Melodie R. Rose ("Attorney-in-Fact"), or any one of
them acting alone, the undersigned's true and lawful attorney-in-fact and
agent with full power of substitution and resubstitution, for the undersigned
and in the undersigned's name, place and stead, in any and all capacities, to
sign any or all Forms 4 or Forms 5 relating to beneficial ownership of
securities of SurModics (the "Issuer"), to file the same, with all exhibits
thereto and other documents in connection therewith, with the Securities and
Exchange Commission and to deliver a copy of the same to the Issuer,
granting unto said attorney-in-fact and agent full power and authority to do
and perform each and every act and thing requisite and necessary to be done
in and about the premises, as fully to all intents and purposes as the
undersigned might or could do in person, hereby ratifying and confirming all
said attorney-in-fact and agent, or his substitute or substitutes, may lawfully
do or cause to be done by virtue thereof. The undersigned acknowledges
that the foregoing attorney-in-fact, in serving in such capacity at the request
of the undersigned, is not assuming any of the undersigned's responsibilities
to comply with Section 16 of the Securities Exchange Act of 1934.
This Power of Attorney shall remain in effect until such time as the
undersigned is no longer subject to the provisions of Section 16 of the
Securities Exchange Act of 1934 with respect to securities of the Issuer or
until this Power of Attorney is replaced by a later dated Power of Attorney or
revoked by the undersigned in writing.
The undersigned hereby indemnifies the Attorneys-in-Fact for all
losses and costs the Attorneys-in-Fact may incur in connection with or
arising from the Attorneys-in-Fact's execution of their authorities granted
hereunder.
IN WITNESS WHEREOF, the undersigned has caused this Power of
Attorney to be executed as of this 17th day of November, 2003.
/s/ Patrick E. Guire
Patrick E. Guire
