-----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, DuJFJ6TLqbvCFWfafXDu/gAiVUzMV0Su6vofq5uBJfz7gF1NGdiJZgYP0BhUVFBc EcX8xV43RCdiu3Vdzw0mgg== 0001209191-04-010277.txt : 20040217 0001209191-04-010277.hdr.sgml : 20040216 20040217104613 ACCESSION NUMBER: 0001209191-04-010277 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20031231 FILED AS OF DATE: 20040217 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: INVACARE CORP CENTRAL INDEX KEY: 0000742112 STANDARD INDUSTRIAL CLASSIFICATION: ORTHOPEDIC, PROSTHETIC & SURGICAL APPLIANCES & SUPPLIES [3842] IRS NUMBER: 952680965 STATE OF INCORPORATION: OH FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: ONE INVACARE WAY STREET 2: P O BOX 4028 CITY: ELYRIA STATE: OH ZIP: 44036 BUSINESS PHONE: 4403296000 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: MIXON AARON MALACHI III CENTRAL INDEX KEY: 0000937770 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 001-15103 FILM NUMBER: 04604707 BUSINESS ADDRESS: STREET 1: 899 CLEVELAND STREET STREET 2: PO BOX 4028 CITY: ELYRIA STATE: OH ZIP: 44036 BUSINESS PHONE: 2166228207 MAIL ADDRESS: STREET 1: 800 SUPERIOR AVENUE STREET 2: SUITE 1800 CITY: CLEVELAND STATE: OH ZIP: 44107 5 1 doc5.xml FORM 5 SUBMISSION X0201 5 2003-12-31 0 0 0 0000742112 INVACARE CORP IVC 0000937770 MIXON AARON MALACHI III ONE INVACARE WAY ELYRIA OH 44036 1 1 0 0 Chairman and CEO Common Shares 2003-10-31 5 G 0 127812.0000 0 D 671945.0000 D Common Shares 2003-10-31 5 G 0 127812.0000 0 D 544133.0000 D Common Shares 2003-11-10 5 G 0 20000.0000 0 D 524133.0000 D Common Shares 2003-12-19 5 G 0 3000.0000 0 D 521133.0000 D Common Shares 2003-10-31 5 G 0 127812.0000 0 A 127812.0000 I By GRAT Common Shares 2003-10-31 5 G 0 127812.0000 0 A 334148.0000 I By Spouse Common Shares 2003-10-31 5 G 0 127812.0000 0 D 206336.0000 I By Spouse Common Shares 2003-10-31 5 G 0 127812.0000 0 A 127812.0000 I By GRAT Common Shares 24576.0000 I By GRAT Common Shares 24577.0000 I By GRAT Common Shares 27316.0000 I By Limited Partnership Common Shares 18410.0000 I By Invacare Retirement Savings Plan Class B Common Shares 703912.0000 D Employee Stock Option (Right to Buy) Common Shares 1493250.0000 1493250.0000 D Owned by the Trustee for the 2003 Grantor Retained Annuity Trust created by the reporting person. The reporting person disclaims beneficial ownership of these securities, and this report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. Owned by the Trustee for the 2003 Grantor Retained Annuity Trust created by the reporting person's spouse. Owned by the Trustee for the 1997 Grantor Retained Annuity Trust created by the reporting person. Owned by the Trustee for the 1997 Grantor Retained Annuity Trust created by the reporting person's spouse. Owned by Roundwood Capital, L.P., a limited partnership of which the General Partner is Roundcap LLC, a limited liability company. The reporting person is one of three Managers and Members of Roundcap LLC and, as such, shares investment and voting power with the other two Managers and Members and participates equally with them in a 15% carried interest in all profits of the partnership. The reporting person is also the owner of a 6.38% limited partnership interest in Roundwood Capital, L.P. The reporting person disclaims beneficial ownership of the shares owned by the limited partnership other than the percentage of such shares which corresponds to his partnership percentage. Owned by Trustee for the Invacare Retirement Savings Plan. The information given is based on a Plan Statement of December 31, 2003, the most recent information reasonably available. No transaction is being reported on this line. Reported on a previously filed Form 3, Form 4, or Form 5. The reporting person holds previously reported options to buy 1,493,250 Common Shares (with tandem tax withholding rights) under the Invacare Corporation 1994 Performance Plan and the Invacare Corporation 2003 Performance Plan, in reliance upon the exemption provided by Rule 16b-3. All options were granted between February 17, 1995 and August 20, 2003, at exercise prices between $17.00 to $37.70 per share, will expire between February 17, 2005 and August 20, 2013 and became or will become exercisable between February 17, 1996 and March 3, 2008. /s/ Aaron Malachi Mixon, III 2004-02-16 -----END PRIVACY-ENHANCED MESSAGE-----