-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, WJq+yiuJ1DALa3pQ5cCAuBFWC8MR94P/CQtw6WvGMl4rUAxi8bxJ2Ik7VJT4Xl1i kXcV4uPlOabX7xbiPhh3qw== 0000906318-03-000033.txt : 20030210 0000906318-03-000033.hdr.sgml : 20030210 20030210112756 ACCESSION NUMBER: 0000906318-03-000033 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021231 FILED AS OF DATE: 20030210 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: LCA VISION INC CENTRAL INDEX KEY: 0001003130 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-SPECIALTY OUTPATIENT FACILITIES, NEC [8093] IRS NUMBER: 112882328 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-27610 FILM NUMBER: 03546291 BUSINESS ADDRESS: STREET 1: 7840 MONTGOMERY RD CITY: CINCINNATI STATE: OH ZIP: 45236 BUSINESS PHONE: 5137929292 MAIL ADDRESS: STREET 1: 7840 MONTGOMERY ROAD CITY: CINCINNATI STATE: OH ZIP: 45236 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: JOFFE SANDRA F W CENTRAL INDEX KEY: 0001030712 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-NURSING & PERSONAL CARE FACILITIES [8050] RELATIONSHIP: OFFICER STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 7840 MONTGOMERY RD CITY: CINCINNATI STATE: OH ZIP: 45236 BUSINESS PHONE: 5137929292 MAIL ADDRESS: STREET 1: 7840 MONTGOMERY ROAD CITY: CINCINNATI STATE: OH ZIP: 45236 5 1 sfwj1202.htm FORM 4

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, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940


OMB APPROVAL            

OMB Number: 3235-0362

Expires: January 31, 2005

Estimated average burden hours per response….1.0

        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

        Form 4 Transactions Reported

 


(Print or Type Responses)

  

1.  Name and Address of Reporting Person*


Joffe

Sandra

F.W.

2.  Issuer Name and Ticker or Trading Symbol


LCA-Vision Inc./LCAV

6.  Relationship of Reporting Person(s) to Issuer

(Check all applicable)


          Director

      X      10% Owner

    X   Officer (give title below)

               Other (specify below)


Secretary

(Last)

(First)

(Middle)



8750 Red Fox Lane

3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary)


4.  Statement for Month/Year


December, 2002

(Street)




Cincinnati, Ohio  45243  

5.  If Amendment, Date of Original Month/Year


7.  Individual or Joint/Group Filing (Check Applicable Line)

             Form filed by One Reporting Person

             Form filed by More than One Reporting Person


(City)

(State)

(Zip)

Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

1. Title of Security

     (Inst. 3)

2. Transaction Date (Month/

Day/Year)

2A. Deemed Execution Date, if any (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 the end of Issuer’s Fiscal Year

(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

       

96,713

I

By GRAT

Common Stock

       

624,585(1)

I

By GRAT

Common Stock

       

743,940

I

By Spouse

Common Stock

       

257,543

I

By Spouse’s GRAT

Common Stock

  


    

1,663,257(2)

I

By Spouse’s GRAT

Common Stock

       

187

D

Jointly with Spouse

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).




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)

2. Conversion or Exercise Price of Derivative Security

3. Trans-action Date (Month/

Day/Year)

3A. Deemed Execution Date, if any (Month/

Day/Year)

4. Trans-action Code (Instr. 8)

5. Number of Derivative Securities Acquired (A) or Disposed of (D)

(Instr. 3, 4 and 5)

6. Date Exercisable and Expiration Date (Month/Day/Year)

7. Title and Amount of Underlying Securities (Instr. 3 and 4)

8. Price of Derivative Security (Instr. 5)

9. Number of Derivative Securities Beneficially Owned at End of Year

(Instr. 4)

10. Ownership of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)

11. Nature of Indirect Beneficial Ownership (Instr. 4)

    

Code

V

(A)

(D)

Date Exer-cisable

Expir-ation Date

Title

Amount or Number of Shares

    

Option (right to buy)

         

Common Stock

  

187

D

 
                
                
                
                
                
                
                

Explanation of Responses:

All amounts reflect a 4 for 1 reverse stock split effective in 2002.

(1)These shares were previously reported as indirectly owned by a GRAT but were contributed to a second grantor retained annuity trust on December 31, 2002.

(2) These shares were previously reported as indirectly owned by a GRAT but were contributed to a second grantor retained annuity trust on December 31, 2002.



**Intentional misstatements or omissions of facts constitute Federal Criminal Violations

/s/Charles F. Hertlein, Jr.

2/7/03

See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)

**Signature of Reporting Person

Date

Sandra F.W. Joffe

Note:  File three copies of this Form, one of which must be manually signed.  If space is insufficient,

by Charles F. Hertlein, Jr.,

see Instruction 6 for procedure.

Attorney-in-fact



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