-----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, B1Yszg1DjD4DEbQmbl6teJQ3Noi5nbUhniyNUNErJKXUbk02aTp8H9Vs3mSMSluB fTGLndnjx8zm2voc0fkXug== 0000351721-03-000013.txt : 20030212 0000351721-03-000013.hdr.sgml : 20030212 20030212093629 ACCESSION NUMBER: 0000351721-03-000013 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021231 FILED AS OF DATE: 20030212 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: NIKOLAEV RICHARD D CENTRAL INDEX KEY: 0001194340 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 5 MAIL ADDRESS: STREET 1: 6501 WINDCREST DR STREET 2: STE 100 CITY: PLANO STATE: TX ZIP: 75024 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: ADVANCED NEUROMODULATION SYSTEMS INC CENTRAL INDEX KEY: 0000351721 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 751646002 STATE OF INCORPORATION: TX FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-10521 FILM NUMBER: 03552596 BUSINESS ADDRESS: STREET 1: 6501 WINDCREST DRIVE SUITE 100 CITY: PLANO STATE: TX ZIP: 75024 BUSINESS PHONE: 9723098000 MAIL ADDRESS: STREET 1: 6501 WINDCREST DRIVE SUITE 100 CITY: PLANO STATE: TX ZIP: 75024 FORMER COMPANY: FORMER CONFORMED NAME: QUEST MEDICAL INC DATE OF NAME CHANGE: 19920703 5 1 nikolaev021503.txt FORM 5 UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 5 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 this box if no longer OMB APPROVAL subject to Section 16. Form 4 or OMB Number: 3235-0362 Form 5 obligations may continue. Expires: Pending See Instruction 1(b). Extimated average burden hours per response.....0.5 - ------------------------------------------------------------------------------- 1. NAME AND ADDRESS OF REPORTING PERSON* LAST FIRST MIDDLE STREET CITY STATE ZIP Nikolaev, Richard D. 11835 N. 83rd Place Scottsdale AZ 85260 - ------------------------------------------------------------------------------- 2. ISSUER NAME AND TICKER OR TRADING SYMBOL Advanced Neuromodulation Systems, Inc., OTC - ANSI - ------------------------------------------------------------------------------- 3. IRS OR SOCIAL SECURITY NUMBER OF REPORTING PERSON (VOLUNTARY) ###-##-#### - ------------------------------------------------------------------------------- 4. STATEMENT FOR MONTH/YEAR 5. IF AMENDMENT, DATE OF ORIGINAL (MONTH/YEAR) December 2002 - ------------------------------------------------------------------------------- 6. RELATIONSHIP OF REPORTING PERSON(S) TO ISSUER (Check all applicable) _X__ Director _____ 10% Owner ____ Officer (give _____ Other (specify title below) below) - ------------------------------------------------------------------------------- 7. INVIDIVUAL OR JOINT/GROUP FILING (Check applicable line) _X__ Form filed by One Reporting Person ____ Form filed by More than One Reporting Person - ------------------------------------------------------------------------------- TABLE 1 - NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF OR BENEFICIALLY OWNED - ------------------------------------------------------------------------------- | 1. Title of Security (Instr. 3) | 2. Transaction | 3. Transaction | | | Date | Code | | | (Month/Day/ | (Instr. 8) | | | Year) | | | | | | | | | | |-------------------------------------|-----------------|----------------------| |Common Stock, $0.05 Par Value | | | |-------------------------------------|-----------------|----------------------| | | | | |-------------------------------------|-----------------|----------------------|
- ------------------------------------------------------------------------------- |4. Securities Acquired | 5. Amount of | 6. Ownership | 7. Nature of | | (A) or Disposed of | Securities | Form: | Indirect | | (D) (Instr. 3, 4, | Beneficially| Direct (D) | Beneficial | | and 5) | Owned at End| or Indirect| Ownership | | | of Month | (I) | (Instr. 4) | | | (Instr. 3 | (Instr. 4) | | | | and 4) | | | - -----------------------------| | | | | | (A) | | | | | | | or | | | | | | Amount | (D) | Price | | | | |-----------|-----|----------|----------------|---------------|----------------| | | | | 24,460 | D | | |-----------|-----|----------|----------------|---------------|----------------| | | | | | | | |-----------|-----|----------|----------------|---------------|----------------|
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) |------------------------------------------------------------------------------| |1. |2. |3. |4. |5. |6. | |Title of |Conver- |Transaction |Trans- |Number of |Date | |Derivative |sion |Date |action |Derivative |Exerciseable | |Security |or |(Month/Day/ |Code |Securities |and | |(Instr. 3) |Exercise |Year) |(Instr. |Acquired (A) or|Expiration | | |Price | |8) |Disposed of (D)|Date | | |of | | |(Instr. 3, 4, |(Month/Day/Year) | | |Deriva- | | |and 5) |-----------------| | |tive | | | |Date |Expira- | | |Security | |--------|-------|-------|Exerc- |tion | | | | | Code | (A) | (D) |isable |Date | |-----------|---------|-------------|--------|-------|-------|--------|--------| |Right to | $5.000 | 11/05/98(1) | A |15,000 | |11/05/98|11/06/04| |Purchase | | | | | | | | |Stock | | | | | | | | |Option | | | | | | | | |-----------|---------|-------------|--------|-------|-------|--------|--------| |Right to | $7.563 | 11/29/99(2) | A | 5,000 | |11/29/00|11/30/05| |Purchase | | | | | | | | |Stock | | | | | | | | |Option | | | | | | | | |-----------|---------|-------------|--------|-------|-------|--------|--------| |Right to | $14.250 | 07/31/00(3) | A | 1,666 | |07/31/01|08/01/06| |Purchase | | | | | | | | |Stock | | | | | | | | |Option | | | | | | | | |-----------|---------|-------------|--------|-------|-------|--------|--------| |Right to | $10.625 | 04/03/01(3) | A | 2,500 | |04/03/02|04/04/07| |Purchase | | | | | | | | |Stock | | | | | | | | |Option | | | | | | | | |-----------|---------|-------------|--------|-------|-------|--------|--------| |Right to | $28.530 | 02/20/02(2) | A | 5,000 | |02/20/03|02/21/08| |Purchase | | | | | | | | |Stock | | | | | | | | |Option | | | | | | | | |-----------|---------|-------------|--------|-------|-------|--------|--------|
|------------------------------------------------------------------------------| |7. |8. |9. |10. |11. | |Title and Amount |Price |Number |Ownership |Nature | |of Underlying |of Derivative|of Derivative|Form of |of | |Securities |Security |Securities |Derivative |Indirect | |(Inst. 3 and 4) |(Instr. 5) |Beneficially |Security: |Beneficial| |------------------------| |Owned at End |Direct (D) or |Ownership | | |Amount or | |of Month |Indirect (I) |(Instr. 4)| | |Number of | |(Instr. 4) |(Instr. 4) | | | Title |Shares | | | | | |------------|-----------|-------------|-------------|--------------|----------| |Common Stock| 15,000 | | | | | |------------|-----------|-------------|-------------|--------------|----------| |Common Stock| 5,000 | | | | | |------------|-----------|-------------|-------------|--------------|----------| |Common Stock| 1,666 | | | | | |------------|-----------|-------------|-------------|--------------|----------| |Common Stock| 2,500 | | | | | |------------|-----------|-------------|-------------|--------------|----------| |Common Stock| 5,000 | | | | | |------------|-----------|-------------|-------------|--------------|----------| | | | TOTAL | 29,166 | D | | |------------|-----------|-------------|-------------|--------------|----------|
Explanation of Responses: (1) Options granted pursuant to Directors' Stock Option Plan, 25% vesting per year. (2) Options granted pursuant to 1998 Stock Option Plan, 25% vesting per year. (3) Options granted pursuant to 2000 Stock Option Plan, 25% vesting per year. Richard D. Nikolaev By:/s/Linda D. Moses, Agent and Attorney-in-Fact for Richard D. Nikolaev - ----------------------------------------------------- **Signature of Reporting Person Date: February 11, 2003 - ----------------------------------------- ** 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 insufficent, see Instruction 6 for procedure. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. -----END PRIVACY-ENHANCED MESSAGE-----