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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN 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. | |||
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. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Prepaid variable forward contract | (1) (2) | 02/11/2005 | J(1)(2) | 50,000 | (1)(2) | (1)(2) | Common Stock | 50,000 | (1) (2) | 50,000 | I | By D. Wentz Limited, Ltd. | |||
Stock Options (Right to buy) | $ 0.74 | 07/30/2002 | 01/30/2012 | Common Stock | 150,000 | 150,000 | D | ||||||||
Stock Options (Right to buy) | $ 2.445 | 01/11/2001 | 01/11/2006 | Common Stock | 50,000 | 50,000 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
WENTZ DAVE 3838 WEST PARKWAY BLVD SALT LAKE CITY, UT 84120 |
President |
David A. Wentz | 02/15/2005 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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) | On February 11, 2005, Dave Wentz, through an affiliated limited partnership, entered into a prepaid variable forward contract (the "Contract") with an unaffiliated third party buyer (the "Buyer"). Pursuant to the Contract, Mr. Wentz has pledged 50,000 shares of common stock of USANA Health Sciences, Inc. to secure his obligation to deliver up to 50,000 shares of common stock on February 12, 2007 (the "Settlement Date"). In exchange, Mr. Wentz will receive $1,869,384, representing 87.6% of the value of the shares on the contract date. |
(2) | (continuation of prior footnote) The actual number of shares Mr. Wentz is obligated to deliver in 2007 varies based on the closing price (the "Settlement Price") of the common stock on the Settlement Date, as follows: (i) if the Settlement Price is at or above $51.216 per share (the "Ceiling Price"), Mr. Wentz is obligated to deliver a number of shares determined by reference to a formula specified in the Contract, (ii) if the Settlement Price is between $42.68 per share (the "Floor Price") and the Ceiling Price, Mr. Wentz is obligated to deliver a number of shares determined by reference to a formula specified in the Contract and (iii) if the Settlement Price is at or below the Floor Price, Mr. Wentz is obligated to deliver 50,000 shares. At Mr. Wentz' option, he may deliver cash in an amount equal to the value of the required number of shares of common stock to be delivered on the Settlement Date. |