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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 5
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(f) of the Investment Company Act of 1940
| o | Check box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
| o | Form 3 Holdings Reported |
| x | Form 4 Transactions Reported |
| 1. | Name and Address of
Reporting Person* |
2. | Issuer Name and Ticker or
Trading Symbol |
3. | I.R.S. Identification
Number of Reporting Person, if an entity (Voluntary) |
|||||||
| Koch David
A. (Last) (First) (Middle) |
SurModics,
Inc.
(SRDX) |
|||||||||||
| 1582A Homestead
Trail |
4. | Statement for Month/Year | 5. | If Amendment, Date of Original (Month/Year) | ||||||||
| September 2002 |
|
|||||||||||
| (Street) | 6. | Relationship of Reporting Person(s) to Issuer (Check All Applicable) |
7. | Individual or Joint/Group
Reporting (Check Applicable Line) |
||||||||
| Long Lake MN
55356 (City) (State) (Zip) |
x | Director | o | 10% Owner | x | Form filed by One Reporting Person | ||||||
| o | Officer (give title below) | o | Form filed by More than One Reporting Person | |||||||||
| o | Other (specify below) | |||||||||||
| * | If the form is filed by more than one reporting person, see instruction 4(b)(v). |
| 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 the End of Issuer's Fiscal Year (Instr. 3 and 4) |
6. | Ownership Form: Direct (D) or Indirect (I) (Instr. 4) |
7. | Nature
of Indirect Beneficial Ownership (Instr. 4) |
|||||||||
| Amount | (A) or (D) |
Price | ||||||||||||||||||||||
| Common Stock | 6/18/02 | G | 50 | D | None | |||||||||||||||||||
| Common Stock | 7/26/02 | P | 260 | A | $20.0571 | 764,720 | D | |||||||||||||||||
| Common Stock | 142,000 | I | Trust (1) | |||||||||||||||||||||
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| 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. | Conversion or Exercise Price of Derivative Security |
3. | Transaction
Date (Month/Day/Year) |
3A. | Deemed Execution Date, if any (Month/Day/Year) |
4. | Transaction Code (Instr. 8) |
5. | Number of Derivative
Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) |
||||||
| (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 | Previously Reported | |||||||||||||||
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| Table II — Derivative
Securities Acquired, Disposed of, or Beneficially Owned —
Continued (e.g., puts, calls, warrants, options, convertible securities) |
|||||||||||||||||
| 6. | Date Exercisable and Expiration Date (Month/Day/Year) |
7. | Title and Amount
of Underlying Securities (Instr. 3 and 4) |
8. | Price of
Derivative Security (Instr. 5) |
9. | Number of Derivative Securities Beneficially Owned at End of Year (Instr. 4) |
10. | Ownership of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. | Nature
of Indirect Beneficial Ownership (Instr. 4) |
||||||
| Date Exercisable |
Expiration Date |
Title | Amount or Number of Shares |
||||||||||||||
| (2) | 5/17/09 | Common Stock | 9,000 | None | 9,000 | D | |||||||||||
| (3) | 9/18/05 | Common Stock | 40,000 | None | 40,000 | D | |||||||||||
| (4) | 9/18/10 | Common Stock | 2,000 | None | 2,000 | D | |||||||||||
| (5) | 11/21/11 | Common Stock | 1,000 | None | 1,000 | D | |||||||||||
Explanation of Responses:
| (1) | These shares are owned by a trust established under the will of Clarissa I. 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 200 shares each commencing 11/21/01. |
| /s/ David A. Koch | November 13, 2002 | |
**Signature of Reporting Person David A. Koch |
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.
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