-----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, QNmNp3g4anC4GZX3OD8JigfYJNmkZjbeQPplDx6zYll1H+zkwnXIQ1ebeFFMtACl C0BhJByj3otCa4rNIF1dKQ== 0001077357-00-000050.txt : 20000215 0001077357-00-000050.hdr.sgml : 20000215 ACCESSION NUMBER: 0001077357-00-000050 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 19991231 FILED AS OF DATE: 20000214 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: SURGICAL SAFETY PRODUCTS INC CENTRAL INDEX KEY: 0001063530 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MISC HEALTH & ALLIED SERVICES, NEC [8090] IRS NUMBER: 650565144 STATE OF INCORPORATION: NY FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: SEC FILE NUMBER: 000-24921 FILM NUMBER: 541708 BUSINESS ADDRESS: STREET 1: 2018 OAK TERRACE CITY: SARASOTA STATE: FL ZIP: 34231 BUSINESS PHONE: 9419277874 MAIL ADDRESS: STREET 1: 2018 OAK TERRACE CITY: SARASOTA STATE: FL ZIP: 34231 COMPANY DATA: COMPANY CONFORMED NAME: SURGICAL SAFETY PRODUCTS INC CENTRAL INDEX KEY: 0001063530 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MISC HEALTH & ALLIED SERVICES, NEC [8090] DIRECTOR IRS NUMBER: 650565144 STATE OF INCORPORATION: NY FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 2018 OAK TERRACE CITY: SARASOTA STATE: FL ZIP: 34231 BUSINESS PHONE: 9419277874 MAIL ADDRESS: STREET 1: 2018 OAK TERRACE CITY: SARASOTA STATE: FL ZIP: 34231 5 1 ANNUAL STATEMENT OF CHANGES FORM 5 OMB Approval OMB Number 3235-0362 Expires: February 1, 1994 U.S. 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(f) of the Investment Company Act of 1940 __ Check if no longer subject to Section 16, Form 4 or Form 5, Obligation may continue. (See Instructions) __ Form 3 Holdings Reported __ Form 4 Transaction Reported 1. Name and Address of Reporting Person: Collins, David 2018 Oak Terrace Sarasota, FL 34231 2. Issuer Name and Ticker or Trading Symbol: SURG 3. IRS or SSN of Reporting Person (Voluntary): 4. Statement for Month/Year 12/31/99 5. If Amendment, Date of Original: 6. Relation of Reporting Person to Issuer X Director _ 10% owner _ Officer (Title): _ Other (Specify) X Filed by One Reporting Person. _ Filed by more than One Reporting Person.
TABLE I - NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED 1. Title of Security: Common Stock 2. Transaction Date: (Last trans date) April 1999 3. Transaction Code: 4. Securities Acquired (A) or Disposed (D): Amount: A or D: Price: 5. Amount of Securities Beneficially owned at end of Issuer's Fiscal Year: 34,000 6. Ownership Form: Direct (D) or Indirect (I): D 7. Nature of Indirect Beneficial Ownership:
*If the form is filed by more than one Reporting Person, see instruction 5(b)(v) Reminder: Report on a separate Line for each class of securities beneficially owned directly or indirectly. FORM 5 (continued) TABLE II - DERIVATIVE SECURITIES BENEFICIALLY OWNED 1. Title of Derivative Security: C.S. Warrants 2. Conversion or Exercise Price of Derivative Security: 3. Transaction Date (M/D/Y): 4. Transaction Code: 5. Number of Derivative Securities Acquired (A) or or Disposed of (D): (A): (D): 6. Date Exercisable: Expiration Date: 7. Title of Underlying Securities: Amount or number of Shares: 8. Price of Derivative Security: 9. Number of Derivative Securities Beneficially Owned at end of Month: 75,000 10. Ownership of Derivative Securities; (D) Direct or (I) Indirect: D 11. Nature of Indirect Beneficial Ownership:
EXPLANATION OF RESPONSES: /s/ David Collins Date: 2/11/2000 - ------------------------------ David Collins **Signature of Reporting Person **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See Sections 18 U.S.C. 1001, 15 U.S.C. 78ff(a).
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