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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 |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Miclot Andrew C/O SYMMETRY MEDICAL, INC. 220 W. MARKET STREET WARSAW, IN 46580 |
Sr VP, Mktg, Sales & Bus Dev |
/s/ Andrew Miclot | 05/17/2005 | |
**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) | Prior to the registration of its common stock, the Issuer repurchased 35.15 shares of Class A Preferred Stock, plus accrued but unpaid dividends thereon, owned by Mr. Miclot, and 159.15 shares of Class A Preferred stock owned by Mr. Miclot were then reclassified as 17,038 shares of common stock. |
(2) | Consists of 2,000 shares of restricted stock issued pursuant to the Issuer's 2004 Equity Incentive Plan. Shares vest on the last day of fiscal 2008 if (i) Mr. Miclot remains an employee of the Issuer through that date and (ii) if the Issuer achieves certain opertating income targets for fiscal years 2005, 2006, 2007 and 2008. |