-----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, OylPS3db1HLWqux096qupwPvJcAOpGcWqsiwF7eitCfK4RCc1cgl6CGwnJ3iSrWx oNNPUkga1ZUVXSK2Aed1ug== 0000931731-03-000217.txt : 20030702 0000931731-03-000217.hdr.sgml : 20030702 20030701183016 ACCESSION NUMBER: 0000931731-03-000217 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20030630 FILED AS OF DATE: 20030702 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: ELLIS JAMES J CENTRAL INDEX KEY: 0001192954 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-18592 FILM NUMBER: 03769201 BUSINESS ADDRESS: STREET 1: C/O MERIT MEDICAL SYSTEMS INC STREET 2: 1600 W MERIT PARKWAY CITY: SOUTH JORDAN STATE: UT ZIP: 84095 BUSINESS PHONE: 8012531600 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: MERIT MEDICAL SYSTEMS INC CENTRAL INDEX KEY: 0000856982 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 870447695 STATE OF INCORPORATION: UT FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1600 WEST MERIT PARK WAY CITY: SOUTH JORDAN STATE: UT ZIP: 84095 BUSINESS PHONE: 8012531600 MAIL ADDRESS: STREET 1: 1600 WEST MERIT PARKWAY CITY: SOUTH JORDAN STATE: UT ZIP: 84095 4 1 form4-jimellis063003_ex.xml X0101 4 2003-06-30 0000856982 MERIT MEDICAL SYSTEMS INC MMSI 0001192954 ELLIS JAMES J 1 0 0 0 Common stock, no par value 2003-06-27 2003-06-27 4 M 0 10156 3.76 A 45719 D Common stock, no par value 2003-06-27 2003-06-27 4 S 0 10156 20.2485 D 37126 D Common stock, no par value 2003-06-30 2003-06-30 4 M 0 11719 2.88 A 47282 D Common stock, no par value 2003-06-30 2003-06-30 4 S 0 11719 20.0021 D 35563 D James J. Ellis per Kent Stanger, Atty in fact per pwr of atty dtd 11/25/95, on file, incorporated 2003-07-01 EX-99 3 jimellis-form4ex99.txt DERIVATIVES-JELLIS-FORM4 - 063003 EXHIBIT 99.1 - Derivative Securities - James Ellis 06/30/03 FORM 4 (continued) ================================================================================ Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
9. 10. Number Owner- of ship 2. Deriv- of Conver- 5. 7. ative Deriv- 11. sion Number of Title and Amount Secur- ative Nature or Derivative 6. of Underlying 8. ities Secur- of Exer- Securities Date Securities Price Bene- ity: In- cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- 4. or Disposed Expiration Date Deriv- Owned (D) or Bene- 1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date action (Instr. 3, or Secur- of direct Owner Derivative ative (Month /Code 4 and 5) Date Expira- Number ity Year (I) -ship Security Secur- Day/ (Instr . Exer- tion of (Instr.(Instr. (Instr. (Instr. (Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) ============================================================================================================================= Non-qual $3.76 06/27/03 M 10,156 05/26/99 05/26/04 Common 10,156 0 D stock Stock options Right to Buy - ----------------------------------------------------------------------------------------------------------------------------- Non-qual $2.88 06/30/03 M 11,719 05/24/00 05/24/05 Common 11,719 0 D stock Stock options Right to Buy - ----------------------------------------------------------------------------------------------------------------------------- Non-qual $5.0624 N/A 05/23/01 05/23/11 Common 15,625 D stock Stock options Right to Buy - ----------------------------------------------------------------------------------------------------------------------------- Non-qual $16.99 N/A 05/23/02 05/23/12 Common 10,000 D stock Stock options Right to Buy - ----------------------------------------------------------------------------------------------------------------------------- Non-qual $18.62 05/22/03 A 15,000 05/22/03 05/22/13 Common 15,000 15,000 D stock Stock options Right to Buy =============================================================================================================================
Explanation of Responses: /s/ JAMES J. ELLIS 07/01/03 - ----------------------------------- ----------- **Signature of Reporting Person Date ** 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 provided is insufficient, see Instruction 6 for procedure. -----END PRIVACY-ENHANCED MESSAGE-----