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.

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