5 1 form5.htm FORM5.HTM Form 5 – Annual Statement of Changes in Beneficial Ownership – EDGAR Services Provided by St Ives Burrups
FORM 5
UNITED STATES 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(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person *

Cipkowski, Stan
(Last)        (First)        (Middle)
 2. Issuer Name American Bio Medica Corporation
     and Ticker or Trading Symbol ABMC
 
 
6. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

Director                          10% Owner
 Officer (give title below)  Other (specify below)

Executive Vice President
122 Smith Road
3. I.R.S. Identification
    Number of Reporting
    Person, if an entity
    (Voluntary)
 
 
 4. Statement for
    Month/Year


12 / 02

(Street)

Kinderhook, NY 12106
5. If Amendment,
    Date of Original
    (Month/Year)


7. Individual or Joint/Group
    Reporting (check applicable line)

 Form filed by One Reporting Person
 Form filed by More than One Reporting Person
(City)        (State)        (Zip)

Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security
    (Instr. 3)

2.Transaction
   Date
   (Month/Day/Year)
2A. Deemed
      Execution
      Date, if any 
      (Month/Day/Year)
 3. Transaction
    Code
    (Instr. 8)
4. Securities Acquired (A) or
    Disposed of (D)
    (Instr. 3, 4, and 5)
5. Amount of
    Securities
    Beneficially
    Owned at end
    of Issuer’s
    Fiscal Year
    (Instr. 3 and 4)
6. Owner-
    ship
    Form:
    Direct (D)
    or
    Indirect (I)
    (Instr. 4)
7.  Nature of
     Indirect
     Beneficial
     Ownership
     (Instr. 4)
Amount
(A) or (D)
Price
Common Shares  7/18/02    G  100,000  D  NA       
Common Shares  7/18/02    G  10,000  D  NA  1,383,000  D   
* If the form is filed by more than one reporting person, see Instruction 4(b)(v). (Over)
    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 Control Number.  

Form 5
(continued)		 Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of
    Derivative
    Security
    (Instr. 3)
2. Conver-
    sion or
    Exer-
    cise
    Price of
    Deriva-
    tive
    Security
3. Trans-
    action
    Date
    (Month/
    Day/
    Year)
3A. Deemed
      Execu-
      tion
      Date, 
      if any
      (Month/
      Day/
      Year)
 4. Trans-
    action
    Code
    (Instr. 8)		 5. Number
    of Deri-
    vative
    Securities
    Acquired
    (A) or
    Disposed
    of (D)
    (Instr. 3, 4
    and 5)
6. Date
    Exercis-
    able
    (DE) and
    Expiration
    Date (ED)
    (Month/
    Day/
    Year)
7. Title and Amount
    of Underlying
    Securities
    (Instr. 3 and 4)
 8. Price of
     Deriv-
     ative
     Security
     (Instr. 5)
 9. Number
    of Deri-
    vative
    Securi-
    ties
    Benefi-
    cially
    Owned
    at End
    of Year
    (Instr. 4)		 10. Owner-
      ship of
      Deriv-
      ative
      Secur-
      ity:
      Direct
      (D) or
      Indirect
      (I)
      (Instr.4) 		11. Nature of
      Indirect
      Benefi-
      cial
      Owner-
      ship
      (Instr. 4)
A
D
DE
ED
   Title   
Amount or
Number
of Shares
Non-Statutory Stock Option  $1.11  7/11/02    A  100,000    7/11/03  7/11/12  Common Shares  100,000    100,000  D   
Explanation of Responses:
Options granted 7/11/02 vest over a 3 year period (i.e. 33%, 33%, 34%)
       
  /s/ Stan Cipkowski   1/15/03
 
 
  ** 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.		  
Potential persons who are to respond to the collection of information contained in this form are not
required to respond unless the form displays a currently valid OMB Number. 		Page 2