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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 | ||||||||
Bonus Award | (1) | 01/29/2005 | A | 0 (1) | (1) | (1) | Common Stock | 0 (1) | $ 0 (1) | 0 (1) | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
COSTELLO RICHARD A C/O ICU MEDICAL INC 951 CALLE AMANECER SAN CLEMENTE, CA 92673 |
Vice President Sales |
By: Lynn DeMartini For: Richard A. Costello | 02/01/2005 | |
**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) | The reported bonus award entitles the reporting person to receive, on the sixth anniversary of the date of the award, cash in the amount of $333,000, subject to certain conditions. If, between the date of the award and the payment date, (A) the market price of the common stock equals or exceeds $50 per share for 10 consecutive trading days, the amount payable at the payment date will be $499,500, or (B) if the issuer's market capitalization equals or exceeds $1 billion for 10 consecutive trading days, the amount payable at the payment daet will be $666,000. Payment may be accelerated if the current chief executive officer of the issuer ceases to be the chief executive officer. |