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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 | $ 3.6 | 12/07/2012 | M | 3,000 | 02/13/2004 | 02/13/2013 | Common Stock | 3,000 | $ 0 | 0 (2) | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
ANDREWS DEBORAH J 1911 WALKER AVENUE MONROVIA, CA 91016 |
VP & Chief Financial Officer |
/s/ Samuel Gesten as attorney-in-fact for Deborah J. Andrews | 12/11/2012 | |
**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 7,500 PARS subject to forfeiture and vesting on March 15, 2014 and 7,500 PARS subject to forfeiture and vesting on March 2, 2015. |
(2) | Following the option exercise by purchase and hold transactions reported on this Form 4, Ms. Andrews' total beneficial ownership (as defined in Rule 13d-3 under the Exchange Act) is 255,000 shares of Common Stock, which includes 213,332 stock options that are vested or will vest within 60 days and 15,000 PARS. She also holds 41,668 unvested stock options. |
Remarks: This Statement on Form 4 reports the cash exercise of expiring options by Ms. Andrews of an aggregate of 3,000 shares of STAAR Surgical Company common stock on December 7, 2012. |