Initial Statement of Beneficial Ownership (3)
July 10 2019 - 7:24PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
Estimated average burden
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
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Hansen Graydon C.
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2. Date of Event Requiring Statement (MM/DD/YYYY)
6/27/2019
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3. Issuer Name
and
Ticker or Trading Symbol
STAAR SURGICAL CO [STAA]
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(Last)
(First)
(Middle)
25651 ATLANTIC OCEAN DRIVE
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
_____ 10% Owner
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X
___ Officer (give title below)
_____ Other (specify below)
Sr. VP, Global Operations /
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(Street)
LAKE FOREST, CA 92630
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
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X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Common Stock
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15000
(1)
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D
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Common Stock Options
(2)
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3/18/2017
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3/17/2026
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Common Stock Options
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4862
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$7.52
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D
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Common Stock Options
(3)
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3/21/2018
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3/20/2027
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Common Stock Options
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15817
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$9.30
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D
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Common Stock Options
(4)
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11/13/2018
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11/12/2027
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Common Stock Options
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7293
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$15.25
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D
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Common Stock Options
(5)
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3/15/2019
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3/14/2028
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Common Stock Options
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12500
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$16.15
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D
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Common Stock Options
(6)
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6/14/2019
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6/13/2028
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Common Stock Options
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6742
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$29.80
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D
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Common Stock Options
(7)
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3/14/2020
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3/13/2029
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Common Stock Options
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23042
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$35.98
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D
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Explanation of Responses:
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(1)
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Includes Restricted Stock Units of Common Stock (RSU), subject to forfeiture rights, which lapse on 11/13/2019 as to 2,083 shares, 11/13/2020 as to 2,084 shares, and 3/17/2020 as to 6,250 shares.
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(2)
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The options granted became exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (3/18/2016) and the remaining 2/3 of such options became exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.
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(3)
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The options granted become exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (3/21/2017) and the remaining 2/3 of such options become exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.
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(4)
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The options granted become exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (11/13/2017) and the remaining 2/3 of such options become exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.
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(5)
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The options granted become exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (3/15/2018) and the remaining 2/3 of such options become exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.
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(6)
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The options granted become exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (6/14/2018) and the remaining 2/3 of such options become exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.
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(7)
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The options granted become exercisable as follows: 1/3 upon completion of 12 months continuous employment from the date of grant (3/14/2019) and the remaining 2/3 of such options become exercisable over the following 24 months in equal amounts on a monthly basis, subject to continuous employment.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Hansen Graydon C.
25651 ATLANTIC OCEAN DRIVE
LAKE FOREST, CA 92630
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Sr. VP, Global Operations
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Signatures
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/s/ Samuel Gesten as attorney-in-fact for Graydon Hansen
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7/10/2019
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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