FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 04/15/2011 |
3. Issuer Name and Ticker or Trading Symbol
STAAR SURGICAL CO [ STAA ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock(1) | 41,500 | D |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Common Stock Options | (2) | 02/26/2014 | Common Stock | 15,000 | $7.86 | D | |
Common Stock Options | (2) | 04/06/2015 | Common Stock | 13,334 | $3.95 | D | |
Common Stock Options | (2) | 04/01/2017 | Common Stock | 15,000 | $5.39 | D | |
Common Stock Options | (2) | 02/13/2018 | Common Stock | 35,000 | $2.3 | D | |
Common Stock Options | (3) | 12/14/2020 | Common Stock | 25,000 | $5.68 | D | |
Common Stock Options | (4) | 03/14/2021 | Common Stock | 20,000 | $5.49 | D |
Explanation of Responses: |
1. Includes (i) 4,000 restricted shares of common stock, subject to forfeiture and vesting in a single installment on March 2, 2012, and (ii) 7,500 Performance Accelerated Restricted Shares of Common Stock (PARS), subject to forfeiture and vesting in a single installment on March 15, 2014, but subject to accelerated vesting as to 1/3 of the shares each year pursuant to achievement of certain performance criteria. |
2. Fully vested and exercisable as of the date of this report. |
3. 8,333 options will vest on December 15, 2011, 8,333 options will vest on December 15, 2012, and the remaining 8,334 options will vest on December 15, 2013. |
4. 6,666 options will vest 3/15/12, 6,667 options will vest on 3/15/13, and the remaining 6,667 shares will vest on 3/15/14. |
Remarks: |
This Statement on Form 3 lists Mr. Subrin's holdings of STAAR Surgical Company Non-Derivative and Derivative Securities as of the date he became subject to Section 16(a) of the Securities Exchange Act of 1934 and the date of this Statement. It does not reflect any transactions in securities of STAAR Surgical Company. |
/s/Charles Kaufman as Attorney-in-Fact for Philippe Subrin | 08/19/2011 | |
** 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 5 (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. |