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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES 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 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Common Stock Options | $ 4.69 | 11/16/2011 | M | 5,000 | (3) | 08/15/2020 | Common Stock | 5,000 | $ 0 | 45,000 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Todd Donald J 1911 WALKER AVE. MONROVIA, CA 91016 |
President, Asia/Pacific |
/s/ Charles Kaufman as Attorney-in-Fact for Donald Todd | 11/18/2011 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Includes 5,000 shares acquired on the exercise of options on November 16, 2011, 7,500 Performance Accelerated Restricted Shars ("PARS") subject to forfeiture and vesting on March 15, 2014 and 2,000 restricted shares subject to forfeiture and vesting on March 2, 2012. |
(2) | Following all reported transactions, Mr. Todd's total beneficial ownership (as defined in Rule 13d-3 under the Exchange Act) is 21,166 shares of Common Stock, which includes 11,666 shares purchasable pursuant to vested options, 7,500 PARS and 2,000 restricted shares. Mr. Todd also holds 53,334 unvested options. |
(3) | Of options to purchase 50,000 shares granted on August 16, 2010, 16,667 shares became exercisable on 8/16/11, 16,666 shares become exercisable on 8/16/12 and 16,667shares become exercisable on 8/16/13. |
Remarks: This Statement on Form 4 reports Mr. Todd's exercise of options to purchase 5,000 shares of STAAR Surgical Company common stock and sale of the purchased shares on November 16, 2011. |