-----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, OLKWZrXPfBhWyDTEGZlRFwuqYH1rrcnKToN8535T+ZVdj4m4ga3oyAkevb1aABy+ pAdCsQrZrd0Hz+BCgz4M0w== 0000950134-04-001023.txt : 20040203 0000950134-04-001023.hdr.sgml : 20040203 20040203121519 ACCESSION NUMBER: 0000950134-04-001023 CONFORMED SUBMISSION TYPE: SC 13G/A PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20040203 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: 1934 Act SEC FILE NUMBER: 005-55203 FILM NUMBER: 04561687 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: KOCH DAVID A CENTRAL INDEX KEY: 0001066677 FILING VALUES: FORM TYPE: SC 13G/A BUSINESS ADDRESS: STREET 1: C/O TRUST U/W CLARISSA GRAY STREET 2: 505 N HIGHWAY 169 SUITE 595 CITY: PLYMOUTH STATE: MN ZIP: 55441 BUSINESS PHONE: 6123402600 MAIL ADDRESS: STREET 1: C/O TRUST U/W CLARISSA GRAY STREET 2: 505 N HIGHWAY 169 SUITE 595 CITY: PLYMOUTH STATE: MN ZIP: 55441 SC 13G/A 1 c82547a5sc13gza.htm AMENDMENT NO. 5 TO SCHEDULE 13G sc13gza
 

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

SCHEDULE 13G

Under the Securities Exchange Act of 1934
(Amendment No. 5)*

SurModics, Inc.

(Name of Issuer)

Common Stock, $.05 par value

(Title of Class of Securities)

868873 10 0

(Cusip Number)

December 31, 2003

(Date of Event Which Requires Filing of this Statement)

Check the appropriate box to designate the rule pursuant to which this Schedule is filed:

        o Rule 13d-1 (b)

        o 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 in 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 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).

 

 

             
13G
CUSIP No. 868873 10 0 Page 2 of 4
  1. Name of Reporting Person:
David A. Koch		 I.R.S. Identification Nos. of above persons (entities only):
  2. Check the Appropriate Box if a Member of a Group:
    (a) o  
    (b) o  
  3. SEC Use Only:
  4. Citizenship or Place of Organization:
U.S.A.
Number of
Shares
Beneficially
Owned by
Each Reporting
Person With
5. Sole Voting Power:
825,820 (includes 51,600 shares which may be purchased upon exercise of options)
6. Shared Voting Power:
240,000
7. Sole Dispositive Power:
825,820 (includes 51,600 shares which may be purchased upon exercise of options)
8.Shared Dispositive Power:
240,000
  9.Aggregate Amount Beneficially Owned by Each Reporting Person:
1,065,820 (includes 51,600 shares which may be purchased upon exercise of options)
  10.Check if the Aggregate Amount in Row (9) Excludes Certain Shares:
o
  11.Percent of Class Represented by Amount in Row (9):
6.1%
  12.Type of Reporting Person:
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 55344-3523
 
Item 2(a)   Name of Person Filing:
 
    See Cover Page Item 1
 
Item 2(b)   Address of Principal Business Office or, if none, residence:
 
    1582A Homestead Trail
Long Lake, MN 55356
 
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 o.

Page 3 of 4 Pages

 

     
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, 2003.

     
    January 30, 2004
 
    (Date)
     
    /s/ David A. Koch
 
    (Signature)
     
    David A. Koch
 
    (Name and title)

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