-----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, V+Pe9/34YJY7CnmPL3WAbhy6fRxgzxRAl1/hHdUsDkU2rILxK+4c9zfoUhhbTHcN vqq79geMiqKO3kfhdcirMg== 0000950134-02-008325.txt : 20020710 0000950134-02-008325.hdr.sgml : 20020710 20020710123409 ACCESSION NUMBER: 0000950134-02-008325 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 3 CONFORMED PERIOD OF REPORT: 20020530 FILED AS OF DATE: 20020710 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: SURMODICS INC CENTRAL INDEX KEY: 0000924717 STANDARD INDUSTRIAL CLASSIFICATION: ADHESIVES & SEALANTS [2891] IRS NUMBER: 411356149 STATE OF INCORPORATION: MN FISCAL YEAR END: 0930 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-23837 FILM NUMBER: 02699589 BUSINESS ADDRESS: STREET 1: 9924 W 74TH ST CITY: EDEN PRAIRIE STATE: MN ZIP: 55344 BUSINESS PHONE: 6128292700 MAIL ADDRESS: STREET 1: 9924 WEST 74TH ST CITY: EDEN PRAIRIE STATE: MN ZIP: 55344 FORMER COMPANY: FORMER CONFORMED NAME: BSI CORP DATE OF NAME CHANGE: 19970506 COMPANY DATA: COMPANY CONFORMED NAME: KOCH DAVID A CENTRAL INDEX KEY: 0001066677 DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: C/O TRUST U/W CLARISSA GRAY STREET 2: 505 N HIGHWAY 169 SUITE 595 CITY: PLYMOUTH STATE: MN ZIP: 55441 BUSINESS PHONE: 6123402600 MAIL ADDRESS: STREET 1: C/O TRUST U/W CLARISSA GRAY STREET 2: 505 N HIGHWAY 169 SUITE 595 CITY: PLYMOUTH STATE: MN ZIP: 55441 4 1 c70566e4.htm FORM 4 e4
 

FORM 4

U.S. SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, DC 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

     
OPEN BALLOT BOX Check box if no longer subject to
Section 16. Form 4 or Form 5 obligations may
continue. See Instruction 1(b).

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(f) of the Investment Company Act of 1940


         
1.   Name and Address of Reporting Person* 2.   Issuer Name and Ticker or Trading Symbol 6.   Relationship of Reporting Person
Koch                     David                    A. SurModics, Inc. (SRDX) to Issuer (Check all applicable)

(Last)                   (First)                   (Middle)

X IN BALLOT BOX Director OPEN BALLOT BOX 10% Owner
OPEN BALLOT BOX Officer (give title below)
3.   IRS Identification Number of Reporting Person, if an Entity (Voluntary) OPEN BALLOT BOX Other (specify below)
1582A Homestead Trail

                                  (Street)


4.   Statement for Month/Year 7.   Individual or Joint/Group Filing
Long Lake               MN                 55356 May 2002 (Check applicable line)  

(City)                   (State)                   (Zip)

X IN BALLOT BOX Form Filed by One Reporting Person
OPEN BALLOT BOX Form Filed by More than One
Reporting Person
5.   If Amendment, Date of Original (Month/Year)



TABLE I — NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED


                         
4.   Securities Acquired (A)
3.   Transaction Code or Disposed of (D)
2.  Transaction Date (Instr. 8) (Instr. 3, 4 and 5)



(A)
or
1.   Title of Security (Instr. 3) (Month/Day/Year) Code V Amount (D) Price







Common Stock 5/30/02 G V 50 D None
Common Stock            
             
             
             

[Additional columns below]

[Continued from above table]
         
5.   Amount of 6.   Ownership Form:
Securities Beneficially Direct (D) or 7.   Nature of Indirect
Owned at End of Month Indirect (I) Beneficial Ownership
(Instr. 3 and 4) (Instr. 4) (Instr. 4)



764,510 D  
142,000 I Trust (1)
     
     
     
     
     

 


 

FORM 4 (CONTINUED)

TABLE II — DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)


                           
5. Number of
Derivative
Securities
Acquired (A) or
4. Transaction Disposed of (D)
Code (Instr. 3, 4,
2. Conversion or (Instr. 8) and 5)
1. Title of Derivative Exercise Price of 3. Transaction Date

Security (Instr. 3) Derivative Security (Month/Day/Year) Code V (A) (D)







Director Stock Option (Right to Buy) $ 6.563 Previously Reported
Director Stock Option (Right to Buy) $ 2.50 Previously Reported
Director Stock Option (Right to Buy) $ 25.094 Previously Reported
Director Stock Option (Right to Buy) $ 34.85 11/12/01 A V   1,000  

[Additional columns below]

[Continued from above table]
                 
6. Date Exercisable 7. Title and Amount
and Expiration of Underlying
Date (Month/Day/ Securities
Year) (Instr. 3 and 4)


8. Price of
Amount or Derivative
Date Expiration Number of Security
Exercisable Date Title Shares (Instr. 5)





(2) 5/17/09 Common Stock 9,000 None
(3) 9/18/05 Common Stock 40,000 None
(4) 9/18/10 Common Stock 2,000 None
(5) 11/12/11 Common Stock 1,000 None

         
9. Number of 10. Ownership
Derivative Form of
Securities Derivative 11. Nature of
Beneficially Securities Indirect
Owned at End Beneficially Beneficial
of Month owned at end of month Ownership
(Instr. 4) (Instr. 4) (Instr. 4)



9,000 D  
40,000 D  
2,000 D  
1,000 D  

      Explanation of Responses:

(1)   These shares are owned by a trust established under the will of Clarissa L. Gray. The wife and children of David A. Koch are among the beneficiaries of the trust. The trustees of the trust are David A. Koch, Paul M. Torgerson and U.S. Bank Trust National Association SD.
(2)   Exercisable in annual increments of 1,800 shares each commencing 5/17/99.
(3)   Exercisable in annual increments of 8,000 shares each commencing 9/18/95.
(4)   Exercisable in annual increments of 400 shares each commencing 9/18/00.
(5)   Exercisable in annual increments of 299 shares each commencing 11/21/01.

     
/s/ David A. Koch
July 3, 2002
**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 is insufficient, see Instruction 6 for procedure.

Page 2

(Print or Type Responses)

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