SEC FORM 3

SEC Form 3

FORM 3

UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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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1. Name and Address of Reporting Person^*

Hayashida Jon K.

(Last)

(First)

(Middle)

25651 ATLANTIC OCEAN DRIVE

(Street)

LAKE FOREST

92630

(City)

(State)

(Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
06/27/2019

3. Issuer Name and Ticker or Trading Symbol
STAAR SURGICAL CO [ STAA ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

	Director	10% Owner
X	Officer (give title below)	Other (specify below)
	VP, Global Clinical, Medical

5. 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 Beneficially Owned
1. Title of Security (Instr. 4)	2. Amount of Securities Beneficially Owned (Instr. 4)	3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock	21,323⁽¹⁾	D

Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4)	2. Date Exercisable and Expiration Date (Month/Day/Year)		3. Title and Amount of Securities Underlying Derivative Security (Instr. 4)		4. Conversion or Exercise Price of Derivative Security	5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	6. Nature of Indirect Beneficial Ownership (Instr. 5)
1. Title of Derivative Security (Instr. 4)	Date Exercisable	Expiration Date	Title	Amount or Number of Shares	4. Conversion or Exercise Price of Derivative Security	5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5)	6. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock Options⁽²⁾	07/27/2016	07/26/2025	Common Stock Options	50,000	$8.64	D
Common Stock Options⁽³⁾	03/18/2017	03/17/2026	Common Stock Options	25,000	$7.52	D
Common Stock Options⁽⁴⁾	03/21/2018	03/20/2027	Common Stock Options	37,500	$9.3	D
Common Stock Options⁽⁵⁾	03/15/2019	03/14/2028	Common Stock Options	25,000	$16.15	D
Common Stock Options⁽⁶⁾	06/14/2019	06/13/2028	Common Stock Options	13,484	$29.8	D
Common Stock Options⁽⁷⁾	03/14/2020	03/13/2029	Common Stock Options	28,026	$35.98	D

Explanation of Responses:

1. Includes 6,250 Restricted Stock Units of Common Stock (RSU), subject to forfeiture rights, which lapse on March 21, 2020.

2. The options granted became exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (7/27/2015) and the remaining 2/3 vested in thirds on the following two anniversaries of the grant date, subject to continuous employment.

3. The options granted became exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (3/18/2016) and the remaining 2/3 of such options became exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.

4. The options granted become exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (3/21/2017) and the remaining 2/3 of such options become exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.

5. The options granted become exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (3/15/2018) and the remaining 2/3 of such options become exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.

6. The options granted become exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (6/14/2018) and the remaining 2/3 of such options become exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.

7. The options granted become exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (3/14/2019) and the remaining 2/3 of such options become exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.

Remarks:

	/s/ Samuel Gesten as attorney-in-fact for Jon Hayashida	07/10/2019
	** 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 5 (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).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number.