------------------------------ OMB APPROVAL ------------------------------ OMB Number: 3235-0362 Expires: January 31, 2005 Estimated average burden hours per response.........1.0 ------------------------------ UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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 |_| Check box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |_| Form 3 Holdings Reported |_| Form 4 Transactions Reported ________________________________________________________________________________ 1. Name and Address of Reporting Person* Lopez, M.D. Diana K. - -------------------------------------------------------------------------------- (Last) (First) (Middle) 951 Calle Amanecer - -------------------------------------------------------------------------------- (Street) San Clemente CA 92673 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol ICU Medical, Inc. (ICUI) ________________________________________________________________________________ 3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year December 2002 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) |_| Director |X| 10% Owner |_| Officer (give title below) |_| Other (specify below) -------------------------------- ________________________________________________________________________________ 7. Individual or Joint/Group Filing (check applicable line) |_| Form filed by One Reporting Person |_| Form filed by More than One Reporting Person ________________________________________________________________________________ ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================ (J) 3:2 stock split in form of stock dividend. (1) Drs. Lopez hold a one-percent general partnership interest in the Partnership. As general partners, they share power to vote and power to dispose of the 1,186,843 shares owned by the Partnership and may be 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's 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) Drs. Lopez are trustees and beneficiaries of the Family Trust. Except to the extent of their pecuniary interests as beneficiaries of the Family Trust, Drs. Lopez disclaim any beneficial ownership of the shares owned by the Family Trust. (3) Held as trustee of the Lopez CRT #1 F/B/O Diana K. Lopez, M.D. and George A. Lopez, M.D.
5. 6. 4. Amount of Owner- Securities Acquired (A) or Securities ship 2A. 3. Disposed of (D) Beneficially Form: 7. 2. Deemed Transaction (Instr. 3, 4 and 5) Owned Direct Nature of Trans- Execution Code ------------------------------- at the End (D) or Indirect 1. action Date, if (Instr. 8) (A) of Issuer's Indirect Beneficial Title of Security Date any ------------ or Fiscal Year (I) Ownership (Instr. 3) (mm/dd/yy) (mm/dd/yy) Amount (D) Price (Instr. 3 & 4) (Instr.4) (Instr.4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock owned by Self 3/15/02 J4 7,653 A 22,959 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock owned by George A. Lopez, M.D. Second Family Limited Partnership 3/15/02 J4 395,871 A 1,186,843 I (1) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock owned by Lopez Family Trust 3/15/02 J4 7,741 A 23,223 I (2) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock owned by Lopez CRT #1 3/15/02 J4 64,800 A 174,400 I (3) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ==================================================================================================================================== FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================ Explanation of Responses: /s/ Diana K. Lopez, M.D. February 12, 2003 - --------------------------------------------- ----------------------- **Signature of Reporting Person Date ** 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 provided is insufficient, see Instruction 6 for procedure.
10. 9. Owner- Number ship 2. of of Conver- 5. 7. Deriv- Deriv- 11. sion Number of Title and Amount ative ative Nature or Derivative 6. of Underlying 8. Secur- Secur- of Exer- 3A. 4. Securities Date Securities Price ities ity: In- cise Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Bene- Direct direct Price 3. Execut- action or Disposed Expiration Date ---------------- Deriv- ficially (D) or Bene- 1. of Trans- ion Code of(D) (Month/Day/Year) Amount ative Owned In- ficial Title of Deriv- action Date if (Instr. (Instr. 3, ---------------- or Secur- at End direct Owner- Derivative ative Date any 8) 4 and 5) Date Expira- Number ity of Year (I) ship Security Secur- (mm/dd/ (mm/dd/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity yy) yy) (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================