-----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, TH4kLnaGAKh27m3NV5Hto2ExdsaedxqhWBv8ooLdVzUtHQ3xA86KUtZNgdjlj3zs 7N6wi+biI8yWbgU/rQwYIg== 0001012975-03-000023.txt : 20030211 0001012975-03-000023.hdr.sgml : 20030211 20030211163158 ACCESSION NUMBER: 0001012975-03-000023 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021228 FILED AS OF DATE: 20030211 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: SCHEIN HENRY INC CENTRAL INDEX KEY: 0001000228 STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-CATALOG & MAIL-ORDER HOUSES [5961] IRS NUMBER: 113136595 STATE OF INCORPORATION: DE FISCAL YEAR END: 1226 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-27078 FILM NUMBER: 03550526 BUSINESS ADDRESS: STREET 1: 135 DURYEA RD CITY: MELVILLE STATE: NY ZIP: 11747 BUSINESS PHONE: 6318425500X6867 MAIL ADDRESS: STREET 1: 135 DURYEA RD CITY: MELVILLE STATE: NY ZIP: 11747 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: BERGMAN STANLEY M CENTRAL INDEX KEY: 0001008413 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: C/O HENRY SCHEIN INC STREET 2: 135 DURYEA ROAD CITY: MELVILLE STATE: NY ZIP: 11747 BUSINESS PHONE: 5168435500 MAIL ADDRESS: STREET 1: C/O HENRY SCHEIN INC STREET 2: 135 DURYEA ROAD CITY: MELVILLE STATE: NY ZIP: 11747 5 1 e106076.txt ------------------------------------ OMB Number: 3235-0362 Expires: January 31, 2005 Estimated average burden hours per response. . . 1.0 ------------------------------------ U.S. 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 [_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). [_] Form 3 Holdings Reported [_] Form 4 Transactions Reported ________________________________________________________________________________ 1. Name and Address of Reporting Person* Bergman Stanley M. - -------------------------------------------------------------------------------- (Last) (First) (Middle) c/o Henry Schein, Inc. 135 Duryea Rd. - -------------------------------------------------------------------------------- (Street) Melville New York 11747 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol Henry Schein, Inc. (HSIC) ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year Fiscal year ended December 28, 2002 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person to Issuer (Check all applicable) [X] Director [_] 10% Owner [X] Officer (give title below) [_] Other (specify below) Chief Executive Officer and President _______________________________________________________________________________ 7. 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 ================================================================================
5. 6. 4. Amount of Owner- 2A. Securities Acquired (A) or Securities ship Deemed Disposed of (D) Beneficially Form: 7. 2. Execution (Instr. 3, 4 and 5) Owned at End Direct Nature of Transaction Date, if 3. ----------------------------- of Issuer's (D) or Indirect 1. Date any Transaction (A) Fiscal Year Indirect Beneficial Title of Security (Month/ (Month/ Code Amount or Price (Instr. 3 (I) Ownership (Instr. 3) Day/Year) Day/Year) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 8/19/02 G 15,000 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 8/27/02 G 30 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 8/30/02 G 10 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 9/26/02 G 12 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 11/7/02 G 920 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 11/7/02 G 460 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 11/7/02 G 460 D - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
*If the form is filed by more than one Reporting Person, see Instruction 4(b)(v). (Over) SEC 2270 (9-02) Page 1 of 3 FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
9. 10. Number Owner- of ship 2. Deriv- of Conver- 5. 7. ative Deriv- 11. sion Number of Title and Amount Secur- ative Nature or 3A. Derivative 6. of Underlying 8. ities Secur- of Exer- Deemed Securities Date Securities Price Bene- ity: In- cise 3. Execu- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- tion 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Date, if Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date any action (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship Security Secur- Day/ Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
/s/ Stanley M. Bergman February 11, 2003 - --------------------------------------------- ----------------------- **Signature of Reporting Person 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. SEC 2270 (9-02) Page 2 of 3 Attachment A to Form 5 Reporting Person: Bergman, Stanley M. Issuer: Henry Schein, Inc. (HSIC) Statement for fiscal year ended December 28, 2002 Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================
1. 2. 2A. 3. 4. 5. 6. 7. Title of Trans- Deemed Trans- Securities Amount of Ownership Nature of Indirect Security action Execution action Acquired Securities Form Direct(D) Beneficial (Instr.3) Date Date, if Code (A) or Beneficially or Indirect Ownership (Month/ any (Instr.8) Disposed Owned at end (I) (Instr. 4) (Instr. 4) Date/ (Month/ of (D) of Issuer's Year) Date/ (Instr. Fiscal Year Year) 3, 4 (Instr. 3 and 5) and 4) ---------- (A) Amount or Price (D) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 11/7/02 G 460 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 11/7/02 G 460 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 11/26/02 G 389 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 11/26/02 G 389 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 10,039 (D) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 716,739 (I) (1) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 19,660 (I) (2) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 778 (I) (3) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 4,800 (I) (4) - ------------------------------------------------------------------------------------------------------------------------------------
Explanation of Responses: - ------------------------ (1) Represents shares held by Stanley M. Bergman's wife and Lawrence O. Sneag as co-trustees of the Stanley M. Bergman Continuing Trust dated September 14, 1994. (2) Represents shares held by Lawrence O. Sneag, Stanley M. Bergman's wife or his sons as trustees of trusts for the benefit of immediate family members of Stanley M. Bergman or certain other persons, wherein Stanley M. Bergman is the grantor. (3) Represents shares held directly by Stanley M. Bergman's sons. (4) Represents shares held by Mark E. Mlotek as custodian for certain family members of Stanley M. Bergman. Page 3 of 3 -----END PRIVACY-ENHANCED MESSAGE-----