-----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, WtKdrW/khy5kQ9PniiQ9Zagp3v4WqoE4dfGkMPt3UXuK13MPgw5wjiFJO0n3N6mI uh7Bv/3cLVuyS9DfUjOF0g== 0000931731-02-000370.txt : 20021107 0000931731-02-000370.hdr.sgml : 20021107 20021107163935 ACCESSION NUMBER: 0000931731-02-000370 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021106 FILED AS OF DATE: 20021107 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: BEAN REX C CENTRAL INDEX KEY: 0001184930 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: 1600 W. MERIT PARKWAY CITY: SOUTH JORDAN STATE: UT ZIP: 84095 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: MERIT MEDICAL SYSTEMS INC CENTRAL INDEX KEY: 0000856982 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 870447695 STATE OF INCORPORATION: UT FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-18592 FILM NUMBER: 02812811 BUSINESS ADDRESS: STREET 1: 1600 WEST MERIT PARK WAY CITY: SOUTH JORDAN STATE: UT ZIP: 84095 BUSINESS PHONE: 8012531600 MAIL ADDRESS: STREET 1: 1600 WEST MERIT PARKWAY CITY: SOUTH JORDAN STATE: UT ZIP: 84095 4 1 rexbean-form4.txt REX BEAN FORM 4 U.S. SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 4 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). - -------------------------------------------------------------------------------- 1. Name and Address of Reporting Person* BEAN REX C. - -------------------------------------------------------------------------------- (Last) (First) (Middle) 1600 West Merit Parkway - -------------------------------------------------------------------------------- (Street) South Jordan UT 84095 - -------------------------------------------------------------------------------- (City) (State) (Zip) - -------------------------------------------------------------------------------- 2. Issuer Name and Ticker or Trading Symbol Merit Medical Systems, Inc. (MMSI) - -------------------------------------------------------------------------------- 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) - -------------------------------------------------------------------------------- 4. Statement for Month/Year November 5, 2002 - -------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Year) Page 1 of 2 Pages - -------------------------------------------------------------------------------- 6. Relationship of Reporting Person to Issuer (Check all applicable) [X] Director [ ] 10% Owner [ ] Officer (give title below) [ ] Other (specify below) - -------------------------------------------------------------------------------- 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- Securities Acquired (A) or Securities ship Disposed of (D) Beneficially Form: 7. 3. (Instr. 3, 4 and 5) Owned at End Direct Nature of 2. Transaction of Issuer's (D) or Indirect 1. Transaction Code (A) Fiscal Year Indirect Beneficial Title of Security Date (Instr. 8) Amount or Price (Instr. 3 (I) Ownership (Instr. 3) (mm/dd/yy) Code V (D) and 4) (Instr.4) (Instr. 4) =========================================================================================================================== Common Stock 11/06/02 G(1) 60,000 D D No Par Value - --------------------------------------------------------------------------------------------------------------------------- Common Stock No Par Value 11/06/02 G 100 D D - --------------------------------------------------------------------------------------------------------------------------- Common Stock No Par Value 11/06/02 G 450 D D - --------------------------------------------------------------------------------------------------------------------------- - --------------------------------------------------------------------------------------------------------------------------- - --------------------------------------------------------------------------------------------------------------------------- Common Stock No Par Value 143,454 - --------------------------------------------------------------------------------------------------------------------------- Common Stock Revocable No Par Value 70,000 I Trust(2) - --------------------------------------------------------------------------------------------------------------------------- * If the form is filed by more than one Reporting Person, see Instruction 4(b)(v). Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
Explanation of Responses: (1) On November 6, 2002, the reporting person contributed 60,000 shares of Merit Medical Systems, Inc. common stock to a charitable remainder trust of which the reporting person is NOT a trustee. The reporting person has an 8% annual interest in the charitable remainder trust and does not have investment or voting control over the shares held by the trust. - -------------------------------------------------------------------------------- (2) On November 6, 2002, the reporting person transferred 70,000 shares of Merit Medical Systems, Inc. from the Bean Family Revocable Trust to the Rex C. Bean Trust. /s/ REX C. BEAN 11/06/02 - ----------------------------------- ----------- by Greg Barnett **Signature of Reporting Person Date Greg Barnett as Attorney-in-Fact pursuant to a Power of Attorney dated September 14, 2002, a manually signed copy of which is on file with the Commission and is incorporated herein by reference. ** 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. Page 2 of 2 Pages -----END PRIVACY-ENHANCED MESSAGE-----