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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: 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)
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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)
Kovalchik, III, M.D. Michael T. ICU Medical, Inc. (ICUI) [X] Director [_] 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 below)
951 Calle Amanacer (Voluntary) April 2000
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(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
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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
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Self, Self and Spouse Jointly 4/20/00 S 3,000 D $19.50 4,175 D
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By Self as Trustee for Children 4/20/00 S 1,700 D $19.50 0 I(b) (a)
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By Spouse in IRA 4/20/00 S 1,650 D $19.50 0 D(b)
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By Nephrology Associates 4/20/00 S 3,250 D $19.50 0 I (a)
Pension Plan
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(a) See first column
(b) Dr. Kovalchik disclaims beneficial ownership of all shares held as custodian and all shares
held by his spouse.
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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. 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
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Options to Acquire Common Stock $ 16.125 5/12/97 4/22/01 Common Stock 3,750
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Options to Acquire Common Stock $ 16.125 4/23/98 4/22/01 Common Stock 3,750
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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)
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N/A 3,750 D
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N/A 3,750 D
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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.
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