SEC Form 3
FORM 3 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 04/29/2015 | 3. Issuer Name and Ticker or Trading Symbol STAAR SURGICAL CO [ STAA ] | |||||||||||||
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
|
Table I - Non-Derivative Securities Beneficially Owned | |||
---|---|---|---|
1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 81,700(1) | D |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
---|---|---|---|---|---|---|---|
1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Common Stock Options (right to buy) | (2) | 02/09/2016 | Common Stock | 25,000 | 6.92 | D | |
Common Stock Options (right to buy) | (3) | 04/01/2017 | Common Stock | 25,000 | 5.39 | D | |
Common Stock Options (right to buy) | (4) | 12/14/2020 | Common Stock | 25,000 | 5.68 | D | |
Common Stock Options (right to buy) | (5) | 03/14/2021 | Common Stock | 20,000 | 5.49 | D | |
Common Stock Options (right to buy) | (6) | 03/01/2022 | Common Stock | 20,000 | 11 | D | |
Common Stock Options (right to buy) | (7) | 03/03/2023 | Common Stock | 20,000 | 5.34 | D | |
Common Stock Options (right to buy) | (8) | 03/06/2024 | Common Stock | 15,000 | 15.54 | D | |
Common Stock Options (right to buy) | (9) | 04/06/2025 | Common Stock | 30,000 | 7.35 | D |
Explanation of Responses: |
1. Includes 7,500 Performance Accelerated Restricted Shares of Common Stock (PARS), subject to forfeiture rights, which lapse on March 4, 2016, but subject to accelerated lapse of the forfeiture rights as to 1/3 of the shares each year pursuant to achievement of crtain performance criteria. Also includes 7,000 Restricted Shares of Common Stock (RSU), subject to forfeiture rights, which lapse as to half of the shares (3500 shares) on March 7, 2016 and half of the shares (3500 shares) on March 7, 2017. Also includes 15,000 Restricted Shares of Common Stock (RSU), subject to forfeiture rights, which lapse as to half of the shares (7500 shares) on April 7, 2017 and half of the shares (7500 shares) on April 7, 2018. |
2. The option becomes exercisable in three equal installments beginning February 10, 2007. |
3. The option becomes exercisable in three equal installments beginning April 2, 2008. |
4. The option becomes exercisable in three equal installments beginning December 15, 2011. |
5. The option becomes exercisable in three equal installments beginning March 15, 2012. |
6. The option becomes exercisable in three equal installments beginning March 2, 2013. |
7. The option becomes exercisable in three equal installments beginning March 4, 2014. |
8. The option becomes exercisable in three equal installments beginning March 7, 2015. |
9. The option becomes exercisable in three equal installments beginning April 7, 2016. |
/s/ Samuel Gesten as attorney-in-fact for Hans-Martin Blickensdoerfer | 05/01/2015 | |
** 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 5 (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. |