-----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, Bjgd8g2nikleAwcH1rteBinhZLdwO/KZuu4A+waVqriFsK0WT+LE/zn9XDr3uSq/ z54m9G1/mflIUsUa2DuY2w== 0000914190-01-000010.txt : 20010123 0000914190-01-000010.hdr.sgml : 20010123 ACCESSION NUMBER: 0000914190-01-000010 CONFORMED SUBMISSION TYPE: SC 13G/A PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20010122 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: SC 13G/A SEC ACT: SEC FILE NUMBER: 005-55203 FILM NUMBER: 1512807 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 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: OLSETH DALE R CENTRAL INDEX KEY: 0001077511 STANDARD INDUSTRIAL CLASSIFICATION: [] FILING VALUES: FORM TYPE: SC 13G/A BUSINESS ADDRESS: STREET 1: 9924 WEST 74TH STREET CITY: EDEN PRAIRIE STATE: MN ZIP: 55344 BUSINESS PHONE: 6128292700 MAIL ADDRESS: STREET 1: 9924 WEST 74TH STREET CITY: EDEN PRAIRIE STATE: MN ZIP: 55344 SC 13G/A 1 0001.txt AMENDMENT 1 TO SCHEDULE 13G SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 SCHEDULE 13G Under the Securities Exchange Act of 1934 (Amendment No. 1)* SurModics, Inc. (Name of Issuer) Common Stock, $.05 par value (Title of Class of Securities) 868873 10 0 (CUSIP Number) December 31, 2000 (Date of Event Which Requires Filing of this Statement) Check the appropriate box to designate the rule pursuant to which this Schedule is filed: [ ] Rule 13d-1(b) [ ] Rule 13d-1(c) [ X ] Rule 13d-1(d) *The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter the disclosures provided in a prior cover page. The information required on the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 ("Act") or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes). Page 1 of 4 Pages SCHEDULE 13G CUSIP No. 868873 10 0 Page 2 of 4 Pages 1 NAMES OF REPORTING PERSONS/I.R.S. IDENTIFICATION NOS. OF ABOVE PERSONS (ENTITIES ONLY) Dale R. Olseth 2 CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP (SEE INSTRUCTIONS) (a) [ ] (b) [ ] 3 SEC USE ONLY 4 CITIZENSHIP OR PLACE OF ORGANIZATION U.S.A. NUMBER OF 5 SOLE VOTING POWER SHARES 1,266,000 (includes 142,000 shares which may be BENEFICIALLY purchased upon exercise of options) OWNED BY 6 SHARED VOTING POWER EACH 5,000 REPORTING 7 SOLE DISPOSITIVE POWER PERSON 1,266,000 (includes 142,000 shares which may WITH be purchased upon exercise of options) 8 SHARED DISPOSITIVE POWER 5,000 9 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON 1,271,000 (includes 142,000 shares which may be purchased upon exercise of options) 10 CHECK IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN SHARES (SEE INSTRUCTIONS) [ ] 11 PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (9) 7.6% 12 TYPE OF REPORTING PERSON (SEE INSTRUCTIONS) IN Answer every item. If an item is inapplicable or the answer is in the negative, so state. Item 1(a) Name of Issuer: SurModics, Inc. Item 1(b) Address of Issuer's Principal Executive Offices: 9924 West 74th Street Eden Prairie, MN 55344 Item 2(a) Name of Person Filing: See Cover Page Item 1 Item 2(b) Address of Principal Business Office or, if none, residence: 9924 West 74th Street Eden Prairie, MN 55344 Item 2(c) Citizenship: See Cover Page Item 4 Item 2(d) Title of Class of Securities: Common Stock, $.05 par value Item 2(e) CUSIP No.: See Cover Page Item 3 Statement filed pursuant to Rule 13d-1(b), or 13d-2(b) or (c): Not applicable Item 4 Ownership See Cover Page Items 5 through 11 Item 5 Ownership of Five Percent or Less of a Class: If this statement is being filed to report the fact that as of the date hereof the reporting person has ceased to be the beneficial owner of more than five percent of the class of securities, check the following [ ]. Item 6 Ownership of More than Five Percent on Behalf of Another Person: Not applicable Item 7 Identification and Classification of the Subsidiary Which Acquired the Security Being Reported on by the Parent Holding Company: Not applicable Item 8 Identification and Classification of Members of the Group: Not applicable Item 9 Notice of Dissolution of Group: Not applicable Item 10 Certifications: Not applicable SIGNATURE After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct as of December 31, 2000. January 19, 2001 (Date) /s/ Dale R. Olseth (Signature) Dale R. Olseth (Name and title) -----END PRIVACY-ENHANCED MESSAGE-----