4 1 sdc295.txt FORM 4 - LACROSSE FOOTWEAR - CARLSON ------------------------------ 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* CARLSON, DAVID P. -------------------------------------------------------------------------------- (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 2, 2003 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Day/Year) ================================================================================ 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) [_] Director [_] 10% Owner [X] Officer (give title below) [_] Other (specify below) Executive Vice President and CFO ________________________________________________________________________________ 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 3,000 D ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ==================================================================================================================================== 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) ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option (Right Common To Buy) $8.625 (1) 01/02/09 Stock 6,750 6,750 D ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option (Right Common To Buy) $4.44 (2) 01/03/10 Stock 1,250 1,250 D ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option (Right Common To Buy) $3.13 (3) 01/02/11 Stock 7,813 7,813 D ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option (Right Common To Buy) $3.40 (4) 01/02/12 Stock 15,000 15,000 D ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option (Right Common To Buy) $2.58 01/02/03 A 20,000 (5) 01/02/13 Stock 20,000 20,000 D ==================================================================================================================================== Explanation of Responses: (1) This option becomes exercisable in 20% increments on January 2, 2000, 2001, 2002, 2003 and 2004, respectively. (2) This option becomes exercisable in 20% increments on January 3, 2001, 2002, 2003, 2004 and 2005, respectively. (3) This option becomes exercisable in 20% increments on January 2, 2002, 2003, 2004, 2005 and 2006, respectively. (4) This option becomes exercisable in 20% increments on January 2, 2003, 2004, 2005, 2006 and 2007, respectively. (5) This option becomes exercisable in 20% increments on January 2, 2004, 2005, 2006, 2007 and 2008, respectively. DAVID P. CARLSON ** 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