-----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, QnwEfmh2Ww2pog9xrJN7DQU/CyF77xY54ldNmDIVD5BY1wcLpt6asnhujQn2Vh57 Io79lZfHw6P5gmPsx7vTHw== 0000897101-03-000108.txt : 20030211 0000897101-03-000108.hdr.sgml : 20030211 20030211141102 ACCESSION NUMBER: 0000897101-03-000108 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021231 FILED AS OF DATE: 20030211 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: VASCULAR SOLUTIONS INC CENTRAL INDEX KEY: 0001030206 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 411859679 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-27605 FILM NUMBER: 03549732 BUSINESS ADDRESS: STREET 1: 2495 XENIUM LANE NORTH CITY: MINNEAPOLIS STATE: MN ZIP: 55441 BUSINESS PHONE: 6125532970 MAIL ADDRESS: STREET 1: 2495 XENIUM LANE NORTH CITY: MINNEAPOLIS STATE: MN ZIP: 55441 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: ROOT HOWARD CENTRAL INDEX KEY: 0001213861 RELATIONSHIP: OFFICER FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: C/O VASCULAR SOLUTIONS INC STREET 2: 2495 XENIUM LN CITY: MINNEAPOLIS STATE: MN ZIP: 55441 BUSINESS PHONE: 7636564300 MAIL ADDRESS: STREET 1: C/O VASCULAR SOLUTIONS INC STREET 2: 2495 XENIUM LN CITY: MINNEAPOLIS STATE: MN ZIP: 55441 5 1 vasc-root030695_form5.htm VASC/ROOT FORM 5 SEC Form 5
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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549

FORM 5

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

o Check this box if no longer subject to Section 16.
Form 4 or Form 5 obligations may continue.
See Instruction 1(b).
o Form 3 Holdings Reported
o Form 4 Transactions Reported
1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or
Trading Symbol		 3. I.R.S. Identification Number of Reporting
Person, if an entity (voluntary)
   Root           Howard               Vascular Solutions, Inc. (VASC)    
 
 (Last)   (First)   (Middle)
4.
Statement for Month/Day/Year
5.
If Amendment, Date of Original (Month/Year)
   2495 Xenium Lane North    12/31/02    
 
(Street)
6.
Relationship of Reporting Person(s)
to Issuer (Check All Applicable)
7.
Individual or Joint/Group Filing
(Check One)
   Minneapolis                MN              55441   x  Director o  10% Owner   x Form filed by One Reporting Person
 
 (City)   (State)   (Zip) 		  x  Officer (give title below)   o Form filed by More than One Reporting Person
    o  Other (specify below)  
       Chief Executive Officer
     
* If the form is filed by more than one reporting person, see instruction 4(b)(v).
 
Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security
(Instr. 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
end of Issuer's
Fiscal Year
(Instr. 3 and 4)		 6. Ownership Form
Direct (D)
Indirect (I)
(Instr. 4)		 7. Nature of Indirect
Beneficial Ownership
(Instr. 4)
  Amount            ¦ (A) or (D) ¦ Price  
   Common Stock    2/28/02        P    5,000  A  $2.70        D    
   Common Stock    5/30/02        P    5,000  A  $1.95        D    
   Common Stock    8/7/02        P    5,000  A  $1.11    290,789    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)		 2. Conversion or Exercise Price of
Derivative Security		 3. Transaction Date
(Month/Day/Year)		 3A. Deemed
Execution Date if any
(Month/Day/Year)		 4. Transaction
Code
(Instr. 8)		 5. Number of Derivative Securities
Acquired (A) or Disposed (D)
(Instr. 3,4, and 5)
  (A) (D)
   Stock Option    $1.50    6/2/97            16,211  
   Stock Option    $6.00    12/22/99            50,000  
   Stock Option    $6.00    12/22/99            50,000  
   Stock Option    $6.00    12/22/99            50,000  
   Stock Option    $6.00    12/22/99            50,000  
   Stock Option    $7.3125    1/22/01            25,000  
   Stock Option    $2.51    10/19/01            25,000  

 
Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned —Continued
  (e.g., puts, calls, warrants, options, convertible securities)
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 Securites 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)
  Date Exercisable Expiration Date   Title Amount or Number of Shares  
   (1)  6/2/07    Common Stock  16,211            D    
   (1)  12/22/09    Common Stock  50,000            D    
   (1)  12/22/09    Common Stock  50,000            D    
   (2)  12/22/09    Common Stock  50,000            D    
   (3)  12/22/09    Common Stock  50,000            D    
   (4)  1/22/11    Common Stock  25,000            D    
   (5)  10/19/11    Common Stock  25,000        266,211    D    
Explanation of Responses:
(1) 100% fully vested. (2) 8.25% on 1/1/02, 8.25% each month thereafter for 10 months and 9.25% on 12/1/02. (3) 8.25% on 1/1/03, 8.25% each month thereafter for 10 months and 9.25% on 12/1/03. (4) 8.25% on 1/1/04, 8.25% each month thereafter for 10 months and 9.25% on 12/1/04. (5) 26% on 10/19/02, and 2% on each month thereafter.



/s/ Howard Root    2/11/03
**Signature of Reporting Person		  
Date
 

Power of Attorney: 

** Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).

File three copies of this Form, one of which must be manually signed. If space is insufficient,
see Instruction 6 for procedure.

Potential persons who are to respond to the collection of information contained in this form are not
required to respond unless the form displays a currently valid OMB Number.
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