SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
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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*
HENSON MICHAEL R

(Last) (First) (Middle)
610 PALOMAR AVENUE

(Street)
SUNNYVALE CA 94085

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
MICRUS ENDOVASCULAR CORP [ MEND ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
06/21/2005
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. 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
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 Following Reported Transaction(s) (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price
Common Stock 74,177 D
Common Stock 25,388 I Michael Henson Annuity Trust No. 1
Common Stock 25,388 I Linda A. Henson Annuity Trust No. 1
Common Stock 2,577 I Michael R. Henson IRA Rollover
Common Stock 2,577 I Linda A. Henson IRA Rollover
Common Stock 06/21/2005 C 19,777 A (1) 45,165 I Michael Henson Annuity Trust No. 1
Common Stock 06/21/2005 C 19,777 A (1) 45,165 I Linda A. Henson Annuity Trust No. 1
Common Stock 06/21/2005 C 123,755 A (1) 123,755 I JAIC-Henson MedFocus Fund, LLC
Common Stock 06/21/2005 C 6,387 A (1) 6,387 I Henson Family Trust
Common Stock 06/21/2005 C 6,666 A (1) 6,666 I Michael R. Henson, TTEE Henson Family Trust 1/8/87
Common Stock 06/21/2005 C 11,695 A (2) 11,695 I Michael R. Henson, TTEE, Henson Family Trust 1/8/97
Common Stock 06/21/2005 X 1,328 A (3) 7,715 I Henson Family Trust
Common Stock 06/21/2005 X 6,200 A (3) 129,955 I JAIC-Henson MedFocus Fund, LLC
Common Stock 06/21/2005 X 1,236 A (3) 131,191 I JAIC-Henson MedFocus Fund, LLC
Common Stock 06/21/2005 X 6,312 A (3) 137,503 I JAIC-Henson MedFocus Fund, LLC
Common Stock 06/21/2005 X 6,312 A (3) 6,312 I JAIC-Henson MedFocus Fund II, LLC
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) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Series A Preferred Stock (1) 06/21/2005 C 19,777 (1) (4) Common Stock 19,777 $0.00 0 I Michael Henson Annuity Trust No. 1
Series A Preferred Stock (1) 06/21/2005 C 19,777 (1) (1) Common Stock 19,777 $0.00 0 I Linda Henson Annuity Trust No. 1
Series B Preferred Stock (2) 06/21/2005 C 8,888 (2) (4) Common Stock 11,695 $0.00 0 I Michael R. Henson, TTEE, Henson Family Trust 1/8/97
Series D Preferred Stock (1) 06/21/2005 C 6,387 (1) (4) Common Stock 6,387 $0.00 0 I Henson Family Trust
Series D Preferred Stock (1) 06/21/2005 C 29,057 (1) (4) Common Stock 29,057 $0.00 0 I JAIC-Henson MedFocus Fund, LLC
Series D-3 Preferrred Stock (1) 06/21/2005 C 6,666 (1) (4) Common Stock 6,666 $0.00 0 I Michael R. Henson, TTEE Henson Family Trust 1/8/87
Series D-3 Preferrred Stock (1) 06/21/2005 C 39,144 (1) (4) Common Stock 39,144 $0.00 0 I JAIC-Henson MedFocus Fund, LLC
Series E Preferred Stock (1) 06/21/2005 C 55,554 (1) (4) Common Stock 55,554 $0.00 0 I JAIC-Henson MedFocus Fund, LLC
Common Warrant(5) $7.52(6) 06/21/2005 X 3,333 (7) (8) Common Stock 3,333 $0.00 0 I Henson Family Trust
Series D Preferred Warrant(9) $7.52 06/21/2005 C 857 (7) (8) Series D Preferred Stock 857 $0.00 0 I Henson Family Trust
Common Stock Warrant(9) $7.52 06/21/2005 C 857 (7) (8) Common Stock 857 $0.00 857 I Henson Family Trust
Common Stock Warrant(9) $7.52(6) 06/21/2005 X 857 (7) (8) Common Stock 857 $0.00 0 I Henson Family Trust
Common Stock Warrant(5) $7.52(6) 06/21/2005 X 19,571 (7) (8) Common Stock 19,571 $0.00 0 I JAIC-Henson MedFocus Fund, LLC
Series D Preferred Warrant(9) $7.52 06/21/2005 C 3,901 (7) (8) Series D Preferred Stock 3,901 $0.00 0 I JAIC-Henson MedFocus Fund, LLC
Common Stock Warrant(9) $7.52 06/21/2005 C 3,901 (7) (8) Common Stock 3,901 $0.00 3,901 I JAIC-Henson MedFocus Fund, LLC
Common Stock Warrant(9) $7.52(6) 06/21/2005 X 3,901 (7) (8) Common Stock 3,901 $0.00 0 I JAIC-Henson MedFocus Fund, LLC
Common Stock Warrant $0.0002(6)(10) 06/21/2005 X 6,312 (7) (11) Common Stock 6,312 $0.00 0 I JAIC-Henson MedFocus Fund, LLC
Common Stock Warrant $0.0002(6)(10) 06/21/2005 X 6,312 (7) (11) Common Stock 6,312 $0.00 0 I JAIC-Henson MedFocus Fund II, LLC
Explanation of Responses:
1. Converts on a 1 to 1 basis.
2. Converts on a 1 to 1.3157894 basis.
3. The shares were acquired by the net exercise of warrants.
4. N/A
5. The Common Warrants were converted and exercised for Common Stock at the closing of the initial public offering.
6. The warrants were net exercised.
7. Immediately Exerciseable
8. Five years from the date of issuance or at the close of initial public offering.
9. The Series D Preferred Warrants were converted and exercised for Common Stock at the closing of the initial public offering.
10. These warrants became exercisable at $0.000225 per share into such number of shares of common stock equal to 1,343,260 multiplied by the quotient of (i) $13.50 less the initial price to the public of $11.00 per share, divided by (ii) the initial price to the public of $11.00 per share.
11. This Warrant (and the right to purchase securities upon exercise hereof) shall terminate upon the earliest to occur of either January 1, 2011, or upon a change of control.
Remarks:
/s/ Michael R. Henson by Robert A. Stern, Attorney-in-Fact. 06/23/2005
** Signature of Reporting Person Date
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).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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