SEC Form 4
FORM 4
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
UNITED STATES SECURITIES AND EXCHANGE COMMISSION | |||
OMB APPROVAL | |||
Washington, D.C. 20549 | |||
OMB Number: | 3235-0287 | ||
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP | Estimated average burden | ||
hours per response: | 0.5 | ||
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
1. Name and Address of Reporting Person*
Miller Franklin J
(Last) | (First) | (Middle) |
1600 W MERIT PARKWAY | ||
(Street) | ||
SOUTH | UT | 84095 |
JORDAN | ||
2. Issuer Name and Ticker or Trading Symbol | 5. Relationship of Reporting Person(s) to Issuer | ||
MERIT MEDICAL SYSTEMS INC[ | (Check all applicable) | ||
MMSI ] | X | Director | 10% Owner |
Officer (give title | Other (specify | ||
3. Date of Earliest Transaction (Month/Day/Year) | below) | below) | |
05/24/2019 | |||
4. If Amendment, Date of Original Filed (Month/Day/Year) | 6. Individual or Joint/Group Filing (Check Applicable | ||
05/29/2019 | Line) | ||
X Form filed by One Reporting Person | |||
Form filed by More than One Reporting | |||
Person |
(City)(State)(Zip)
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) | 2. Transaction | 2A. Deemed | 3. | 4. Securities Acquired (A) or | 5. Amount of | 6. Ownership | 7. Nature | ||||||||||||||||||||||||
Date | Execution Date, | Transaction | Disposed Of (D) (Instr. 3, 4 | Securities | Form: Direct | of Indirect | |||||||||||||||||||||||||
(Month/Day/Year) | if any | Code (Instr. | and 5) | Beneficially | (D) or | Beneficial | |||||||||||||||||||||||||
(Month/Day/Year) | 8) | Owned | Indirect (I) | Ownership | |||||||||||||||||||||||||||
Following | (Instr. 4) | (Instr. 4) | |||||||||||||||||||||||||||||
Code | V | Amount | (A) or | Price | Reported | ||||||||||||||||||||||||||
Transaction(s) | |||||||||||||||||||||||||||||||
(D) | |||||||||||||||||||||||||||||||
(Instr. 3 and 4) | |||||||||||||||||||||||||||||||
By the | |||||||||||||||||||||||||||||||
Franklin | |||||||||||||||||||||||||||||||
J. Miller | |||||||||||||||||||||||||||||||
Common Stock, No Par Value | 18,193 | I | and | ||||||||||||||||||||||||||||
Bonnie | |||||||||||||||||||||||||||||||
A. Miller | |||||||||||||||||||||||||||||||
Family | |||||||||||||||||||||||||||||||
Trust | |||||||||||||||||||||||||||||||
Common Stock, No Par Value | 14,038 | D | |||||||||||||||||||||||||||||
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned | |||||||||||||||||||||||||||||||
(e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||||||||||||||||||
1. Title of | 2. | 3. Transaction | 3A. Deemed | 4. | 5. Number | 6. Date Exercisable and | 7. Title and | 8. Price | 9. Number of | 10. | 11. Nature | ||||||||||||||||||||
Derivative | Conversion | Date | Execution Date, | Transaction | of | Expiration Date | Amount of | of | derivative | Ownership | of Indirect | ||||||||||||||||||||
Security | or Exercise | (Month/Day/Year) | if any | Code (Instr. | Derivative | (Month/Day/Year) | Securities | Derivative | Securities | Form: | Beneficial | ||||||||||||||||||||
(Instr. 3) | Price of | (Month/Day/Year) | 8) | Securities | Underlying | Security | Beneficially | Direct (D) | Ownership | ||||||||||||||||||||||
Derivative | Acquired | Derivative | (Instr. 5) | Owned | or Indirect | (Instr. 4) | |||||||||||||||||||||||||
Security | (A) or | Security (Instr. 3 | Following | (I) (Instr. | |||||||||||||||||||||||||||
Disposed | and 4) | Reported | 4) | ||||||||||||||||||||||||||||
of (D) | Transaction(s) | ||||||||||||||||||||||||||||||
(Instr. 3, 4 | (Instr. 4) | ||||||||||||||||||||||||||||||
and 5) | |||||||||||||||||||||||||||||||
Amount | |||||||||||||||||||||||||||||||
or | |||||||||||||||||||||||||||||||
Number | |||||||||||||||||||||||||||||||
Date | Expiration | of | |||||||||||||||||||||||||||||
Code | V | (A) | (D) | Exercisable | Date | Title | Shares | ||||||||||||||||||||||||
Non- | |||||||||||||||||||||||||||||||
qualified | |||||||||||||||||||||||||||||||
stock | $9.95 | 05/22/2014(1) | 05/22/2020 | Common | 20,000 | 20,000 | D | ||||||||||||||||||||||||
options | Stock | ||||||||||||||||||||||||||||||
(right to | |||||||||||||||||||||||||||||||
buy) | |||||||||||||||||||||||||||||||
Non- | |||||||||||||||||||||||||||||||
qualified | |||||||||||||||||||||||||||||||
stock | $13.99 | 06/11/2015(2) | 06/11/2021 | Common | 25,000 | 25,000 | D | ||||||||||||||||||||||||
options | Stock | ||||||||||||||||||||||||||||||
(right to | |||||||||||||||||||||||||||||||
buy) | |||||||||||||||||||||||||||||||
Non- | |||||||||||||||||||||||||||||||
qualified | |||||||||||||||||||||||||||||||
stock | $20.27 | 05/22/2016(3) | 05/22/2022 | Common | 25,000 | 25,000 | D | ||||||||||||||||||||||||
options | Stock | ||||||||||||||||||||||||||||||
(right to | |||||||||||||||||||||||||||||||
buy) | |||||||||||||||||||||||||||||||
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of | 2. | 3. Transaction | 3A. Deemed | 4. | 5. Number | 6. Date Exercisable and | 7. Title and | 8. Price | 9. Number of | 10. | 11. Nature | |||||
Derivative | Conversion | Date | Execution Date, | Transaction | of | Expiration Date | Amount of | of | derivative | Ownership | of Indirect | |||||
Security | or Exercise | (Month/Day/Year) | if any | Code (Instr. | Derivative | (Month/Day/Year) | Securities | Derivative | Securities | Form: | Beneficial | |||||
(Instr. 3) | Price of | (Month/Day/Year) | 8) | Securities | Underlying | Security | Beneficially | Direct (D) | Ownership | |||||||
Derivative | Acquired | Derivative | (Instr. 5) | Owned | or Indirect | (Instr. 4) | ||||||||||
Security | (A) or | Security (Instr. 3 | Following | (I) (Instr. | ||||||||||||
Disposed | and 4) | Reported | 4) | |||||||||||||
of (D) | Transaction(s) | |||||||||||||||
(Instr. 3, 4 | (Instr. 4) | |||||||||||||||
and 5) | ||||||||||||||||
Amount | ||||||||||||||||
or | ||||||||||||||||
Number | ||||||||||||||||
Date | Expiration | of | ||||||||||||||
Code | V | (A) | (D) | Exercisable | Date | Title | Shares | |||||||||
Non- | ||||||||||||||||
qualified | ||||||||||||||||
stock | $18.8 | 05/26/2017(4) | 05/26/2023 | Common | 25,000 | 25,000 | D | |||||||||
options | Stock | |||||||||||||||
(right to | ||||||||||||||||
buy) | ||||||||||||||||
Non- | ||||||||||||||||
qualified | ||||||||||||||||
stock | $34.4 | 05/24/2018(5) | 05/24/2024 | Common | 25,000 | 25,000 | D | |||||||||
options | Stock | |||||||||||||||
(right to | ||||||||||||||||
buy) | ||||||||||||||||
Non- | ||||||||||||||||
qualified | ||||||||||||||||
stock | $50.5 | 06/07/2019(6) | 06/07/2025 | Common | 25,000 | 25,000 | D | |||||||||
options | Stock | |||||||||||||||
(right to | ||||||||||||||||
buy) | ||||||||||||||||
Non- | ||||||||||||||||
qualified | ||||||||||||||||
stock | $52.17(7) | 05/24/2019 | A | 13,750 | 05/24/2020(8) | 05/24/2026 | Common | 13,750 | $0 | 13,750 | D | |||||
options | Stock | |||||||||||||||
(right to | ||||||||||||||||
buy) | ||||||||||||||||
Explanation of Responses:
- Becomes exercisable in equal annual installments of 20% commencing 05/22/2014.
- Becomes exercisable in equal annual installments of 20% commencing 06/11/2015.
- Becomes exercisable in equal annual installments of 20% commencing 05/22/2016.
- Becomes exercisable in equal annual installments of 20% commencing 05/26/2017.
- Becomes exercisable in equal annual installments of 20% commencing 05/24/2018.
- Becomes exercisable in equal annual installments of 20% commencing 06/07/2019.
- Due to a clerical error, the reporting person is filing this Form 4/A to correct the exercise price of the derivative security reported on the initial Form 4 filed on May 29, 2019, from $53.95 to $52.17.
- Becomes exercisable in equal annual installments of 33% commencing 05/24/2020.
Remarks:
Brian G. Lloyd, Attorney-in- | 05/29/2019 | |
Fact | ||
** Signature of Reporting Person Date |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. * If the form is filed by more than one reporting person, see Instruction 4 (b)(v).
-
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 insufficient, see Instruction 6 for procedure.
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number.
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Disclaimer
Merit Medical Systems Inc. published this content on 29 May 2019 and is solely responsible for the information contained herein. Distributed by Public, unedited and unaltered, on 29 May 2019 23:38:03 UTC