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- -------- U.S. SECURITIES AND EXCHANGE COMMISSION --------------------------------
FORM 4 Washington, D.C. 20549 OMB APPROVAL
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[_] 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)
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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. Diana K. ICU Medical, Inc. (ICUI) [ ] Director [X] 10% Owner
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(Last) (First) (Middle) 3. IRS or Social 4. Statement for ____ Officer (give ____ Other (specify
Security Number of Month/Year title below)
Reporting Person February 1999 below)
951 Calle Amanecer (Voluntary)
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(Street) 5. If Amendment, -------------------------------
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
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_____ Form filed by More than One Reporting
Person
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(City) (State) (Zip) Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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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)
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Common Stock owned by self 12,006 D
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Common Stock owned by Lopez CRT #1 250,000 I (1)
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Common Stock owned by
George A. Lopez, M.D. 2/24/99 J(2) 791,742 A 21.00(2) 791,942 I (2)
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Second Family Limited Partnership
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(1) Held as trustee of the Lopez CRT #1 F/B/O Diana K. Lopez, M.D. and George A. Lopez, M.D.
(2) 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 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'
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.
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)
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FORM 4 (continued) Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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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
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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)
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Explanation of Responses:
** Intentional misstatements or /s/ Diana K. Lopez 3-9-99
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)
