- -------- U.S. SECURITIES AND EXCHANGE COMMISSION -------------------------------- FORM 4 Washington, D.C. 20549 OMB APPROVAL - -------- -------------------------------- [_] Check this box if no STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OMB Number: 3235-0287 longer subject to Expires: September 30, 1998 Section 16. Form 4 Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Estimated average burden or Form 5 obligations Section 17(a) of the Public Utility Holding Company Act of 1935 hours per response.......... 0.5 may continue. See or Section 30(f) of the Investment Company Act of 1940 -------------------------------- Instruction 1(b). (Print or Type Responses) - ----------------------------------------------------------------------------------------------------------------------------------- 1. Name and Address of 2. Issuer Name and Ticker or 6. Relationship of Reporting Person to Issuer Reporting Person* Trading Symbol (Check all applicable) Lopez, M.D. George A. ICU Medical, Inc. (ICUI) [X] Director [ ] 10% Owner - ---------------------------------------------------------------------------------- (Last) (First) (Middle) 3. IRS or Social 4. Statement for X Officer (give ____ Other (specify Security Number of Month/Year ---- title below) Reporting Person February 1999 below) 951 Calle Amanecer (Voluntary) President, Chief Executive Officer - -------------------------------- ---------------------- ----------------------------------- (Street) 5. If Amendment, and Chairman of the Board Date of Original ------------------------- San Clemente, CA 92673 (Month/Year) 7. Individual or Joint/Group Filing (Check Applicable Line) X Form filed by One Reporting Person ---- ____ Form filed by More than One Reporting Person - ------------------------------------------------------------------------------------------------------------------------------------ (City) (State) (Zip) Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Owner- 7. Nature of (Instr. 3) action action or Disposed of (D) Securities ship Indirect Date Code (Instr. 3, 4 and 5) Beneficially Form: Beneficial (Instr. 8) Owned at Direct Ownership (Month/ ------------------------------------------- End of Month (D) or In- (Instr. 4) Day/ (A) or (Instr. 3 direct (I) Year) Code V Amount (D) Price and 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 2/24/99 J(1) 791,742 A 21.00(1) 791,742(2) I (1) - ------------------------------------------------------------------------------------------------------------------------------------ (1) George A. Lopez, M.D. and Diana K. Lopez, M.D., his wife, are the general partners of the George A. Lopez, M.D. Second Family Limited Partnership (the "Partnership") and hold a one-percent general partnership interest in the Partnership. As general partners, they share power to vote and power to dispose of the 791,739 shares owned by the Partnership and may deemed to be beneficial owners of such shares. The Partnership acquired the shares on 2/24/99 from Trusts for the benefit of the Lopez' children, the Christopher George Lopez Children's Trust and the Nicholas George Lopez Children's Trust, which own a 99% limited partnership interest in the Partnership. The Drs. Lopez are not trustees of and have no interest in their children's Trusts. Except to the extent of their undivided one percent general partnership interest in the assets of the Partnership, the Drs. Lopez disclaim any beneficial ownership of the shares owned by the Partnership. (2) Excludes 250,000 Common Shares are hold in Lopez Trust CRT #1. Also excludes 12,006 shares held by Dr. Lopez' wife. Dr. Lopez disclaims any beneficial interest in the shares held by the Trust and by his wife. Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over) * If the form is filed by more than one reporting person, see Instruction 4(b)(v). SEC 1474 (7-96) FORM 4 (continued) Table II - Derivative Securities Acquired, Disposed of, of Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) - -----------------------------------------------------------------------------------------------------------------------------------
Explanation of Responses: ** Intentional misstatements or /s/ George A. Lopez M.D. 3/9/1999 omissions of facts constitute -------------------------- -------------- Federal Criminal Violations. **Signature of Date See 18 U.S.C. 1001 and Reporting Person 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. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. Page 2 SEC 1474 (7-96)1. Title of Derivative 2. Cover- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount of Security (Instr. 3) sion or action action Derivative cisable and Underlying Securities Exercise Date Code Securities Expiration (Instr. 3 and 4) Price of (Month/ (Instr. 8) Acquired (A) Date (Month/ Deriv- Day/ or Disposed Day/Year) ative Year) of (D) (Instr. ---------------------------------------- Security 3, 4, and 5) Date Expira- Amount or -------------------------------- Exer- tion Title Number of Code V (A) (D) cisable Date Shares - ------------------------------------------------------------------------------------------------------------------------------------ Options to Acquire 11.25 1/30/99 10/13/05 Common Stock 100,000 - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 8.19 2/12/99 10/3/07 Common Stock 298,000 - ------------------------------------------------------------------------------------------------------------------------------------ 8.31 1/30/99 1/31/08 Common Stock 280,000 - ------------------------------------------------------------------------------------------------------------------------------------ 15.37 1/30/99 6/26/07 Common Stock 380,000 - ------------------------------------------------------------------------------------------------------------------------------------ 12.25 * 1/2/09 Common Stock 650,000 - ------------------------------------------------------------------------------------------------------------------------------------ 12.25 1/30/99 1/2/09 Common Stock 32,655 - ------------------------------------------------------------------------------------------------------------------------------------ 12.25 * 1/2/09 Common Stock 67,345 - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ----------------------------------------------------------------------------------------------------------------------------------- 1. Title of Derivative 8. Price 9. Number 10. Ownership 11. Nature of Security (Instr. 3) of of Form of Indirect Deriv- Deriv- Derivative Beneficial ative ative Security: Ownership Security Securities Direct (D) (Instr. 4) (Instr. 5) Beneficially or Indirect Owned at (I) End of Month (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ N/A 100,000 D - ------------------------------------------------------------------------------------------------------------------------------------ N/A 298,000 D - ------------------------------------------------------------------------------------------------------------------------------------ N/A 280,000 D - ------------------------------------------------------------------------------------------------------------------------------------ N/A 380,000 D - ------------------------------------------------------------------------------------------------------------------------------------ N/A 650,000 D - ------------------------------------------------------------------------------------------------------------------------------------ N/A 32,655 D - ------------------------------------------------------------------------------------------------------------------------------------ N/A 67,345 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ * Options exercisable on 1/2/08 or earlier upon achievement of certain performance objectives, as specified in the option agreement.