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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
SCHEDULE 13G
Under the Securities Exchange Act of 1934
(Amendment No. 5)*
SurModics, Inc.
Common Stock, $.05 par value
868873 10 0
December 31, 2003
Check the appropriate box to designate the rule pursuant to which this Schedule is filed:
o Rule 13d-1 (b)
o Rule 13d-1 (c)
x Rule 13d-1 (d)
*The remainder of this cover page shall be filled out for a
reporting person’s initial filing on this form with respect to the subject
class of securities, and for any subsequent amendment containing information
which would alter the disclosures provided in a prior cover page.
The information required in the remainder of this cover page
shall not be deemed to be “filed” for the purpose of Section 18
of the Securities Exchange Act of 1934 or otherwise subject to the liabilities
of that section of the Act but shall be subject to all other provisions of the
Act (however, see the notes).
| 13G | ||||||
| CUSIP No. 868873 10 0 | Page 2 of 4 | |||||
| 1. | Name of Reporting Person: David A. Koch |
I.R.S. Identification Nos. of above
persons (entities only): |
||||
| 2. | Check the Appropriate Box if a Member of a Group: | |||||
| (a) | o | |||||
| (b) | o | |||||
| 3. | SEC Use Only: | |||||
| 4. | Citizenship or Place of
Organization: U.S.A. |
|||||
| Number
of Shares Beneficially Owned by Each Reporting Person With | ||||||
| 5. | Sole Voting Power: 825,820 (includes 51,600 shares which may be purchased upon exercise of options) | |||||
| 6. | Shared Voting Power: 240,000 | |||||
| 7. | Sole Dispositive Power: 825,820 (includes 51,600 shares which may be purchased upon exercise of options) | |||||
| 8. | Shared Dispositive Power: 240,000 | |||||
| 9. | Aggregate Amount Beneficially Owned by Each Reporting Person:
1,065,820 (includes 51,600 shares which may be purchased upon exercise of options) |
|||||
| 10. | Check if the Aggregate Amount in Row (9) Excludes Certain
Shares: o |
|||||
| 11. | Percent of Class Represented by Amount in Row
(9): 6.1% | |||||
| 12. | Type of Reporting Person: IN | |||||
Answer every item. If an item is inapplicable or the answer is in the negative, so state.
| Item 1(a) | Name of Issuer: | |
| SurModics, Inc. | ||
| Item 1(b) | Address of Issuer’s Principal Executive Offices: | |
|
9924 West 74th Street Eden Prairie, MN 55344-3523 |
||
| Item 2(a) | Name of Person Filing: | |
| See Cover Page Item 1 | ||
| Item 2(b) | Address of Principal Business Office or, if none, residence: | |
|
1582A Homestead Trail Long Lake, MN 55356 |
||
| Item 2(c) | Citizenship: | |
| See Cover Page Item 4 | ||
| Item 2(d) | Title of Class of Securities: | |
| Common Stock, $.05 par value | ||
| Item 2(e) | CUSIP No.: | |
| See Cover Page | ||
| Item 3 | Statement filed pursuant to Rule 13d-1(b), or 13d-2(b) or (c): | |
| Not applicable | ||
| Item 4 | Ownership | |
| See Cover Page Items 5 through 11 | ||
| Item 5 | Ownership of Five Percent or Less of a Class: | |
| If this statement is being filed to report the fact that as of the date hereof the reporting person has ceased to be the beneficial owner of more than five percent of the class of securities, check the following o. |
Page 3 of 4 Pages
| Item 6 | Ownership of More than Five Percent on Behalf of Another Person: | |
| Not applicable | ||
| Item 7 | Identification and Classification of the Subsidiary Which Acquired the Security Being Reported on by the Parent Holding Company: | |
| Not applicable | ||
| Item 8 | Identification and Classification of Members of the Group: | |
| Not applicable | ||
| Item 9 | Notice of Dissolution of Group: | |
| Not applicable | ||
| Item 10 | Certifications: | |
| Not applicable |
SIGNATURE
After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct as of December 31, 2003.
| January 30, 2004 | ||
|
|
||
| (Date) | ||
| /s/ David A. Koch | ||
|
|
||
| (Signature) | ||
| David A. Koch | ||
|
|
||
| (Name and title) | ||
Page 4 of 4 Pages