-----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, JKOfpQqXo+9ysTXTBtZJZ7aXxKeYl1LCVVn3FfV4gr+ErNxF3/0tszH6yK9mZfY6 9qJR9G6zGDKohawtQ46WSQ== 0000904454-09-000614.txt : 20091028 0000904454-09-000614.hdr.sgml : 20091028 20091028155430 ACCESSION NUMBER: 0000904454-09-000614 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20091026 FILED AS OF DATE: 20091028 DATE AS OF CHANGE: 20091028 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: CLARK JOHN D CENTRAL INDEX KEY: 0001212995 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-34494 FILM NUMBER: 091141749 MAIL ADDRESS: STREET 1: 320 PARK AVENUE STE 2500 CITY: NEW YORK STATE: NY ZIP: 10022 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: AGA Medical Holdings, Inc. CENTRAL INDEX KEY: 0001421419 STANDARD INDUSTRIAL CLASSIFICATION: ELECTROMEDICAL & ELECTROTHERAPEUTIC APPARATUS [3845] IRS NUMBER: 204757212 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 5050 NATHAN LANE N CITY: PLYMOUTH STATE: MN ZIP: 55442 BUSINESS PHONE: 763-513-9227 MAIL ADDRESS: STREET 1: 5050 NATHAN LANE N CITY: PLYMOUTH STATE: MN ZIP: 55442 4 1 edgar.xml PRIMARY DOCUMENT X0303 4 2009-10-26 0001421419 AGA Medical Holdings, Inc. AGAM 0001212995 CLARK JOHN D C/O WELSH, CARSON, ANDERSON & STOWE 320 PARK AVENUE, SUITE 2500 NEW YORK NY 10022 0 0 1 0 Common Stock 2009-10-26 4 C 0 19749603 A 23913988 I By Welsh, Carson, Anderson & Stowe IX, L.P. Common Stock 2009-10-26 4 C 0 1210197 A 1210197 I By WCAS Capital Partners IV, L.P. Common Stock 2009-10-26 4 C 0 15558 A 19854 D Series A Preferred Stock 2009-10-26 4 C 0 116789 D Common Stock 19749603 0 I By Welsh, Carson, Anderson & Stowe IX, L.P. Series A Preferred Stock 2009-10-26 4 C 0 6524 D Common Stock 1103241 0 I By WCAS Capital Partners IV, L.P. Series A Preferred Stock 2009-10-26 4 C 0 92 D Common Stock 15558 0 D Series B Preferred Stock 2009-10-26 4 C 0 1879 D Common Stock 106956 0 I By WCAS Capital Partners IV, L.P. Upon consummation of the Issuer's initial public offering, each share of Preferred Stock automatically converted into Common Stock, for no additional consideration. The number of shares of Common Stock received upon conversion of Preferred Stock included shares issued in payment of accrued and unpaid dividends on such Preferred Stock as of the date of conversion. Reflects the 7.15 for 1 reverse split of the Common Stock effective concurrently with the conversion of the Preferred Stock. The Reporting Person is a managing member of the respective sole general partners of Welsh, Carson, Anderson & Stowe IX, L.P. and WCAS Capital Partners IV, L.P. Pursuant to Instruction (4)(b)(iv) of Form 4, the Reporting Person has elected to report as indirectly beneficially owned the entire number of securities beneficially owned by each such entity. The Reporting Person disclaims beneficial ownership of any securities, and any proceeds thereof, that exceed his pecuniary interest therein and/or that are not actually distributed to him. /s/David Mintz, Attorney-in-Fact 2009-10-27 -----END PRIVACY-ENHANCED MESSAGE-----