4 1 irm95.txt FORM 4 ------------------------------ OMB APPROVAL ------------------------------ OMB Number 3235-0287 Expires: January 31, 2005 Estimated average burden hours per response ....... 0.5 ------------------------------ UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 4 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 [_] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). ________________________________________________________________________________ 1. Name and Address of Reporting Person* SCHNEIDER, VIRGINIA F. -------------------------------------------------------------------------------- (Last) (First) (Middle) C/O LACROSSE FOOTWEAR, INC. 18550 NE RIVERSIDE PARKWAY -------------------------------------------------------------------------------- (Street) PORTLAND, OREGON 97230 -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol LACROSSE FOOTWEAR, INC. (BOOT) ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Day/Year January 13, 2003 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Day/Year) ================================================================================ 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) [_] Director [X] 10% Owner [_] Officer (give title below) [_] Other (specify below) ________________________________________________________________________________ 7. Individual or Joint/Group Filing (Check applicable line) [X] Form filed by one Reporting Person [_] Form filed by more than one Reporting Person ________________________________________________________________________________ ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================
5. 6. 2A. 4. Amount of Owner- Deemed Securities Acquired (A) or Securities ship 2. Execution 3. Disposed of (D) Beneficially Form: 7. Transaction Date, if Transaction (Instr. 3, 4 and 5) Owned Follow- Direct Nature of Date any Code ------------------------------- ing Reported (D) or Indirect 1. (Month/ (Month/ (Instr. 8) (A) Transaction(s) Indirect Beneficial Title of Security Day/ Day/ ------------ Amount or Price (Instr. 3 (I) Ownership (Instr. 3) Year) Year) Code V (D) and 4) (Instr.4) (Instr. 4) ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 01/13/03 Z V 10,000 D 1,139,515 I By Trust(1) ------------------------------------------------------------------------------------------------------------------------------------ As Trustee of Voting Common Stock 01/13/03 Z V 110,000(2) D 1,474,294(3) I Trust ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 01/13/03 Z V 10,000 A 141,919 I By Trust ------------------------------------------------------------------------------------------------------------------------------------ As Trustee of Charitable Common Stock 51,999(3) I Foundation ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ==================================================================================================================================== 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 4(b)(v). Persons who respond to the collection of information contained in this form are not required to respond (Over) unless the form displays a currently valid OMB control number. SEC 1474 (9-02)
FORM 4 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ====================================================================================================================================
10. 9. Owner- Number ship of Deriv- Form 2. ative of Conver- 5. 7. Secur- Deriv- 11. sion Number of Title and Amount ities ative Nature or 3A. Derivative 6. of Underlying 8. Benefi- Secur- of Exer- Deemed 4. Securities Date Securities Price cially ity: In- cise 3. Execu- Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Owned Direct direct Price Trans- tion action or Disposed Expiration Date ---------------- Deriv- Following (D) or Bene- 1. of action Date, Code of(D) (Month/Day/Year) Amount ative Reported In- ficial Title of Deriv- Date if any (Instr. (Instr. 3, ---------------- or Secur- Trans- direct Owner- Derivative ative (Month/ (Month/ 8) 4 and 5) Date Expira- Number ity action(s) (I) ship Security Secur- Day/ Day/ ------ ------------ Exer- tion of (Instr (Instr (Instr (Instr (Instr. 3) ity Year) Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ==================================================================================================================================== Explanation of Responses: (1) All of such shares are deposited in the voting trust. (2) Reflects withdrawals from the voting trust by persons other than the reporting person. (3) 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. VIRGINIA F. SCHNEIDER ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ Luke E. Sims 1/14/03 ------------------------------------- ---------- See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ** Signature of Reporting Person Date Luke E. Sims, Attorney-in-Fact Note: File three copies of this Form, one of which must be manually signed. If space 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