SEC Form 5
FORM 5
Check this 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.
UNITED STATES SECURITIES AND EXCHANGE COMMISSION | |||
OMB APPROVAL | |||
Washington, D.C. 20549 | |||
OMB Number: | 3235-0362 | ||
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL | Estimated average burden | ||
hours per response: | 1.0 | ||
OWNERSHIP | |||
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[ MMSI | (Check all applicable) | |||
] | X | Director | 10% Owner | |
Officer (give title | Other (specify | |||
3. | Statement for Issuer's Fiscal Year Ended (Month/Day/Year) | below) | below) | |
12/31/2019 | ||||
4. | If Amendment, Date of Original Filed (Month/Day/Year) | 6. Individual or Joint/Group Filing (Check Applicable | ||
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 Disposed Of | 5. Amount of | 6. | 7. Nature of | ||||||||||||||||||||
Date | Execution Date, | Transaction | (D) (Instr. 3, 4 and 5) | Securities | Ownership | Indirect | |||||||||||||||||||||
(Month/Day/Year) | if any | Code (Instr. | Beneficially | Form: Direct | Beneficial | ||||||||||||||||||||||
(Month/Day/Year) | 8) | (A) or | Owned at end of | (D) or | Ownership | ||||||||||||||||||||||
Amount | Price | Issuer's Fiscal | Indirect (I) | (Instr. 4) | |||||||||||||||||||||||
(D) | Year (Instr. 3 and | (Instr. 4) | |||||||||||||||||||||||||
4) | |||||||||||||||||||||||||||
By the | |||||||||||||||||||||||||||
Franklin J. | |||||||||||||||||||||||||||
Miller and | |||||||||||||||||||||||||||
Common Stock, No Par Value | 29,897(1) | I | Bonnie A. | ||||||||||||||||||||||||
Miller | |||||||||||||||||||||||||||
Family | |||||||||||||||||||||||||||
Trust | |||||||||||||||||||||||||||
Common Stock, No Par Value | 2,334 | 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 Amount | 8. Price | 9. Number of | 10. | 11. Nature | ||||||||||||||||
Derivative | Conversion | Date | Execution Date, | Transaction | of | Expiration Date | of Securities | of | derivative | Ownership | of Indirect | ||||||||||||||||
Security | or Exercise | (Month/Day/Year) | if any | Code (Instr. | Derivative | (Month/Day/Year) | Underlying | Derivative | Securities | Form: | Beneficial | ||||||||||||||||
(Instr. 3) | Price of | (Month/Day/Year) | 8) | Securities | Derivative Security | Security | Beneficially | Direct (D) | Ownership | ||||||||||||||||||
Derivative | Acquired | (Instr. 3 and 4) | (Instr. 5) | Owned | or Indirect | (Instr. 4) | |||||||||||||||||||||
Security | (A) or | Following | (I) (Instr. 4) | ||||||||||||||||||||||||
Disposed | Reported | ||||||||||||||||||||||||||
of (D) | Transaction(s) | ||||||||||||||||||||||||||
(Instr. 3, 4 | (Instr. 4) | ||||||||||||||||||||||||||
and 5) | |||||||||||||||||||||||||||
Amount | |||||||||||||||||||||||||||
or | |||||||||||||||||||||||||||
Number | |||||||||||||||||||||||||||
Date | Expiration | of | |||||||||||||||||||||||||
(A) | (D) | Exercisable | Date | Title | Shares | ||||||||||||||||||||||
Non- | |||||||||||||||||||||||||||
qualified | |||||||||||||||||||||||||||
stock | $9.95 | 05/22/2014(2) | 05/22/2020 | Common | 20,000 | 20,000 | D | ||||||||||||||||||||
options | Stock | ||||||||||||||||||||||||||
(right to | |||||||||||||||||||||||||||
buy) | |||||||||||||||||||||||||||
Non- | |||||||||||||||||||||||||||
qualified | |||||||||||||||||||||||||||
stock | $13.99 | 06/11/2015(3) | 06/11/2021 | Common | 25,000 | 25,000 | D | ||||||||||||||||||||
options | Stock | ||||||||||||||||||||||||||
(right to | |||||||||||||||||||||||||||
buy) | |||||||||||||||||||||||||||
Non- | |||||||||||||||||||||||||||
qualified | |||||||||||||||||||||||||||
stock | $20.27 | 05/22/2016(4) | 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 Amount | 8. Price | 9. Number of | 10. | 11. Nature | ||||
Derivative | Conversion | Date | Execution Date, | Transaction | of | Expiration Date | of Securities | of | derivative | Ownership | of Indirect | ||||
Security | or Exercise | (Month/Day/Year) | if any | Code (Instr. | Derivative | (Month/Day/Year) | Underlying | Derivative | Securities | Form: | Beneficial | ||||
(Instr. 3) | Price of | (Month/Day/Year) | 8) | Securities | Derivative Security | Security | Beneficially | Direct (D) | Ownership | ||||||
Derivative | Acquired | (Instr. 3 and 4) | (Instr. 5) | Owned | or Indirect | (Instr. 4) | |||||||||
Security | (A) or | Following | (I) (Instr. 4) | ||||||||||||
Disposed | Reported | ||||||||||||||
of (D) | Transaction(s) | ||||||||||||||
(Instr. 3, 4 | (Instr. 4) | ||||||||||||||
and 5) | |||||||||||||||
Amount | |||||||||||||||
or | |||||||||||||||
Number | |||||||||||||||
Date | Expiration | of | |||||||||||||
(A) | (D) | Exercisable | Date | Title | Shares | ||||||||||
Non- | |||||||||||||||
qualified | |||||||||||||||
stock | $18.8 | 05/26/2017(5) | 05/26/2023 | Common | 25,000 | 25,000 | D | ||||||||
options | Stock | ||||||||||||||
(right to | |||||||||||||||
buy) | |||||||||||||||
Non- | |||||||||||||||
qualified | |||||||||||||||
stock | $34.4 | 05/24/2018(6) | 05/24/2024 | Common | 25,000 | 25,000 | D | ||||||||
options | Stock | ||||||||||||||
(right to | |||||||||||||||
buy) | |||||||||||||||
Non- | |||||||||||||||
qualified | |||||||||||||||
stock | $50.5 | 06/07/2019(7) | 06/07/2025 | Common | 25,000 | 25,000 | D | ||||||||
options | Stock | ||||||||||||||
(right to | |||||||||||||||
buy) | |||||||||||||||
Non- | |||||||||||||||
qualified | |||||||||||||||
stock | $52.17 | 05/24/2020(8) | 05/24/2026 | Common | 13,750 | 13,750 | D | ||||||||
options | Stock | ||||||||||||||
(right to | |||||||||||||||
buy) | |||||||||||||||
Non- | |||||||||||||||
qualified | |||||||||||||||
stock | $52.17 | 05/31/2020(9) | 05/31/2026 | Common | 7,500 | 7,500 | D | ||||||||
options | Stock | ||||||||||||||
(right to | |||||||||||||||
buy) | |||||||||||||||
Explanation of Responses:
- This Form 5 is being filed to report the transfer of 11,704 shares transferred into the Franklin J. Miller and Bonnie A. Miller Family Trust from the reporting person's directly held shares, a transaction exempt form Section 16 reporting pursuant to Rule 16a-13.
- 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.
- Becomes exercisable in equal annual installments of 20% commencing 05/24/2020.
- Becomes exercisable in equal annual installments of 20% commencing 05/31/2020.
Brian G. Lloyd, Attorney-in- | 01/29/2020 | |
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.
Attachments
- Original document
- Permalink
Disclaimer
Merit Medical Systems Inc. published this content on 29 January 2020 and is solely responsible for the information contained therein. Distributed by Public, unedited and unaltered, on 29 January 2020 17:04:05 UTC