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:

  1. 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.
  2. Becomes exercisable in equal annual installments of 20% commencing 05/22/2014.
  3. Becomes exercisable in equal annual installments of 20% commencing 06/11/2015.
  4. Becomes exercisable in equal annual installments of 20% commencing 05/22/2016.
  5. Becomes exercisable in equal annual installments of 20% commencing 05/26/2017.
  6. Becomes exercisable in equal annual installments of 20% commencing 05/24/2018.
  7. Becomes exercisable in equal annual installments of 20% commencing 06/07/2019.
  8. Becomes exercisable in equal annual installments of 20% commencing 05/24/2020.
  9. 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.

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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