-----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, TcHCphx88JYNwJqchn+PW+2dQ2lSL1H2qrFPePuhVClMAq/xGfYE3wKvNs1iNp0M SXNRYeNQiaPgiNZ/q6oelw== 0001019687-03-000239.txt : 20030213 0001019687-03-000239.hdr.sgml : 20030213 20030213165705 ACCESSION NUMBER: 0001019687-03-000239 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021231 FILED AS OF DATE: 20030213 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: ICU MEDICAL INC/DE CENTRAL INDEX KEY: 0000883984 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 330022692 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-19974 FILM NUMBER: 03560597 BUSINESS ADDRESS: STREET 1: 951 CALLE AMANECER CITY: SAN CLEMENTE STATE: CA ZIP: 92769 BUSINESS PHONE: 9493662183 MAIL ADDRESS: STREET 1: 951 CALLE AMANELER CITY: SANCLEMENTE STATE: CA ZIP: 92769 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: LOPEZ DIANA K CENTRAL INDEX KEY: 0001081096 RELATIONSHIP: OWNER FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 95 CALLE AMANECER CITY: SAN CLEMENTE STATE: CA ZIP: 92673 BUSINESS PHONE: 9493662183 MAIL ADDRESS: STREET 1: C/O ICU MEDICAL INC STREET 2: 951 CALLE AMANECER CITY: SAN CLEMENTE STATE: CA ZIP: 92673 5 1 lopez_f5-123102.txt ------------------------------ OMB APPROVAL ------------------------------ OMB Number: 3235-0362 Expires: January 31, 2005 Estimated average burden hours per response.........1.0 ------------------------------ UNITED STATES 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(h) 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* Lopez, M.D. Diana K. - -------------------------------------------------------------------------------- (Last) (First) (Middle) 951 Calle Amanecer - -------------------------------------------------------------------------------- (Street) San Clemente CA 92673 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol ICU Medical, Inc. (ICUI) ________________________________________________________________________________ 3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year December 2002 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) |_| Director |X| 10% Owner |_| Officer (give title below) |_| Other (specify below) -------------------------------- ________________________________________________________________________________ 7. Individual or Joint/Group Filing (check applicable line) |_| 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 2A. 3. Disposed of (D) Beneficially Form: 7. 2. Deemed Transaction (Instr. 3, 4 and 5) Owned Direct Nature of Trans- Execution Code ------------------------------- at the End (D) or Indirect 1. action Date, if (Instr. 8) (A) of Issuer's Indirect Beneficial Title of Security Date any ------------ or Fiscal Year (I) Ownership (Instr. 3) (mm/dd/yy) (mm/dd/yy) Amount (D) Price (Instr. 3 & 4) (Instr.4) (Instr.4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock owned by Self 3/15/02 J4 7,653 A 22,959 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock owned by George A. Lopez, M.D. Second Family Limited Partnership 3/15/02 J4 395,871 A 1,186,843 I (1) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock owned by Lopez Family Trust 3/15/02 J4 7,741 A 23,223 I (2) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock owned by Lopez CRT #1 3/15/02 J4 64,800 A 174,400 I (3) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
(J) 3:2 stock split in form of stock dividend. (1) Drs. Lopez hold a one-percent general partnership interest in the Partnership. As general partners, they share power to vote and power to dispose of the 1,186,843 shares owned by the Partnership and may be deemed to be beneficial owners of such shares. The Partnership acquired the shares on 2/24/99 from Trusts for the benefit of the Lopez's children, the Christopher George Lopez Children's Trust and the Nicholas George Lopez Children's Trust, which own a 99% limited partnership interest in the Partnership. The Drs. Lopez are not trustees of and have no interest in their children's Trusts. Except to the extent of their undivided one percent general partnership interest in the assets of the Partnership, the Drs. Lopez disclaim any beneficial ownership of the shares owned by the Partnership. (2) Drs. Lopez are trustees and beneficiaries of the Family Trust. Except to the extent of their pecuniary interests as beneficiaries of the Family Trust, Drs. Lopez disclaim any beneficial ownership of the shares owned by the Family Trust. (3) Held as trustee of the Lopez CRT #1 F/B/O Diana K. Lopez, M.D. and George A. Lopez, M.D. FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
10. 9. Owner- Number ship 2. of of Conver- 5. 7. Deriv- Deriv- 11. sion Number of Title and Amount ative ative Nature or Derivative 6. of Underlying 8. Secur- Secur- of Exer- 3A. 4. Securities Date Securities Price ities ity: In- cise Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Bene- Direct direct Price 3. Execut- action or Disposed Expiration Date ---------------- Deriv- ficially (D) or Bene- 1. of Trans- ion Code of(D) (Month/Day/Year) Amount ative Owned In- ficial Title of Deriv- action Date if (Instr. (Instr. 3, ---------------- or Secur- at End direct Owner- Derivative ative Date any 8) 4 and 5) Date Expira- Number ity of Year (I) ship Security Secur- (mm/dd/ (mm/dd/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity yy) yy) (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: /s/ Diana K. Lopez, M.D. February 12, 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. -----END PRIVACY-ENHANCED MESSAGE-----