UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Employee Stock Option (right to buy) | Â (1)(4) | 06/05/2012 | Common Stock | 145,000 | $ 0.8 | D | Â |
Employee Stock Option (right to buy) | Â (2) | 07/11/2013 | Common Stock | 24,125 | $ 0.8 | D | Â |
Employee Stock Option (right to buy) | Â (3)(4) | 02/17/2015 | Common Stock | 113,750 | $ 0.8 | D | Â |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Merselis James D C/O HEMOSENSE, INC. 651 RIVER OAKS PKWY SAN JOSE, CA 95134 |
 X |  X |  President, CEO |  |
/s/ James D. Merselis | 06/13/2005 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 5(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | This option vests and becomes exercisable as to (i) 14,500 shares immediately, (ii) 21,750 shares upon the achievement of certain milestones and (iii) 1/42nd of the remaining 108,750 shares on the 1st day of each month beginning on December 3, 2002. |
(2) | Immediately. |
(3) | This option vests and becomes exercisable as to 25% of the shares on February 17, 2006 and 1/48th of the shares on the 1st day of each month thereafter. |
(4) | This option will also immediately vest as to 20% of the shares upon the effective date of the issuer's Registration Statement on Form S-1 estimated to be on or around June 13, 2005. |