SEC Form 5

5 1 vasc-nagel030693_form5.htm VASC/NAGEL FORM 5 SEC Form 5

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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

o	Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
o	Form 3 Holdings Reported
o	Form 4 Transactions Reported

Name and Address of Reporting Person*

Issuer Name and Ticker or
Trading Symbol

I.R.S. Identification Number of Reporting
Person, if an entity (voluntary)

Nagel Michael

Vascular Solutions, Inc. (VASC)

(Last) (First) (Middle)

Statement for Month/Day/Year

If Amendment, Date of Original (Month/Year)

2495 Xenium Lane North

12/31/02

(Street)

Relationship of Reporting Person(s)
to Issuer (Check All Applicable)

Individual or Joint/Group Filing
(Check One)

Minneapolis MN 55441

Director

10% Owner

Form filed by One Reporting Person

(City) (State) (Zip)

Officer (give title below)

Form filed by More than One Reporting Person

Other (specify below)

VP of Sales & Marketing

* If the form is filed by more than one reporting person, see instruction 4(b)(v).

Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

1. Title of Security
(Instr. 3) 2. Transaction Date
(Month/Day/Year) 2A. Deemed Execution
Date, if any
(Month/Day/Year) 3. Transaction
Code
(Instr. 8) 4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5) 5. Amount of Securities
Beneficially Owned at
end of Issuer's
Fiscal Year
(Instr. 3 and 4) 6. Ownership Form
Direct (D)
Indirect (I)
(Instr. 4) 7. Nature of Indirect
Beneficial Ownership
(Instr. 4)

Amount ¦ (A) or (D) ¦ Price

Common Stock 4/30/02 M 577 A $1.6575 D

Common Stock 10/31/02 M 1,571 A $.6375 54,565 D

Common Stock 18,000 I (1)

Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)

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 (D)
(Instr. 3,4, and 5)

(A) (D)

Stock Option $1.50 6/2/97 45,000

Stock Option $2.51 10/19/01 20,000

Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned —Continued
(e.g., puts, calls, warrants, options, convertible securities)

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 Securites Beneficially Owned at End of Year
(Instr. 4) 10. Ownership of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4) 11. Nature of Indirect Beneficial Ownership
(Instr. 4)

Date Exercisable Expiration Date Title Amount or Number of Shares

(2) 6/2/07 Common Stock 45,000 D

(3) 10/19/11 Common Stock 20,000 65,000 D

Explanation of Responses:
(1) The 18,000 shares are registered in the name of Mr. Nagel's three minor children's irrevocable trusts. (2) 100% fully vested. (3) 26% on 10/19/02, 2% monthly thereafter.

/s/ Michael Nagel 2/11/03

**Signature of Reporting Person
Date

Power of Attorney:

** Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).

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
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/s/ Michael Nagel		2/11/03
**Signature of Reporting Person		Date