- -------- 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: December 31, 2001 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) Kovalchik, III, M.D. Michael T. ICU Medical, Inc. (ICUI) [X] Director [_] 10% Owner - ---------------------------------------------------------------------------------- (Last) (First) (Middle) 3. IRS or Social 4. Statement for ____ Officer (give ____ Other (specify Security Number of Month/Year title below) Reporting Person below) 951 Calle Amanacer (Voluntary) April 2000 - -------------------------------- ---------------------- -------------------------------------------------- (Street) 5. If Amendment, 7. Individual or Joint/Group Filing (Check Applicable Line) Date of Original ____ Form filed by One Reporting Person San Clemente CA 92673 (Month/Year) ____ 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 - ------------------------------------------------------------------------------------------------------------------------------------ Self, Self and Spouse Jointly 4/20/00 S 3,000 D $19.50 4,175 D - ----------------------------------------------------------------------------------------------------------------------------------- By Self as Trustee for Children 4/20/00 S 1,700 D $19.50 0 I(b) (a) - ----------------------------------------------------------------------------------------------------------------------------------- By Spouse in IRA 4/20/00 S 1,650 D $19.50 0 D(b) - ----------------------------------------------------------------------------------------------------------------------------------- By Nephrology Associates 4/20/00 S 3,250 D $19.50 0 I (a) Pension Plan - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- (a) See first column (b) Dr. Kovalchik disclaims beneficial ownership of all shares held as custodian and all shares held by his spouse. - ----------------------------------------------------------------------------------------------------------------------------------- Page 1 SEC 1474 (11-99) FORM 4 (CONTINUED) TABLE II - DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) - -----------------------------------------------------------------------------------------------------------------------------------
Explanation of Responses: ** Intentional misstatements or /s/ Michael T. Kovalchik 5/10/2000 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 provided is insufficient, see Instruction 6 for procedure. Page 2 SEC 1474 (11-99)1. Title of Derivative 2. Conver- 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 Number of (A) (D) cisable Date Title Shares - ------------------------------------------------------------------------------------------------------------------------------------ Options to Acquire Common Stock $ 16.125 5/12/97 4/22/01 Common Stock 3,750 - ------------------------------------------------------------------------------------------------------------------------------------ Options to Acquire Common Stock $ 16.125 4/23/98 4/22/01 Common Stock 3,750 - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ----------------------------------------------------------------------------------------------------------------------------------- 8. Price 9. Number 10. Ownership 11. Nature of of of 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 Year (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ N/A 3,750 D - ------------------------------------------------------------------------------------------------------------------------------------ N/A 3,750 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------