X0304 4 2011-10-20 0001460198 Kips Bay Medical, Inc. KIPS 0001310813 Smith Arch C 3405 ANNAPOLIS LANE SUITE 200 MINNEAPOLIS MN 55447 1 0 0 0 Common Stock 34200 D Stock Option (right to buy) 5.83 2018-11-24 Common Stock 25000 25000 D Stock Option (right to buy) 2.00 2011-10-20 4 A 0 18750 0 A 2021-10-20 Common Stock 18750 18750 D Includes 30,000 shares of restricted stock that vest in 7,500 share increments on each of 2/16/12, 2/16/13, 2/16/14 and 2/16/15. 6,250 shares vest on each of 11/24/08, 11/24/09, 11/24/10 and 11/24/11. 6,250 shares vest on each of 10/20/12, 10/20/13 and 10/20/14. /s/ Scott Dorfman as Attorney-in-Fact for Arch C. Smith pursuant to Power of Attorney previously filed. 2011-10-24