Statement of Changes in Beneficial Ownership (4)
07 November 2018 - 11:10PM
Edgar (US Regulatory)
FORM 4
[
X
]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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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
*
Myers Burton F. II
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2. Issuer Name
and
Ticker or Trading Symbol
WSI INDUSTRIES, INC.
[
WSCI
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
222 SOUTH NINTH STREET, SUITE 3050
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3. Date of Earliest Transaction
(MM/DD/YYYY)
11/7/2018
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(Street)
MINNEAPOLIS, MN 55402
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock
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0
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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. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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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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Stock Option (Right-to-Buy)
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$6.13
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11/7/2018
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D
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2000
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(1)
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12/18/2018
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Common Stock
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2000
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(2)
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0
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D
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Stock Option (Right-to-Buy)
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$6.16
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11/7/2018
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D
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2000
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(1)
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12/18/2019
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Common Stock
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2000
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(2)
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0
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D
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Stock Option (Right-to-Buy)
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$4.37
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11/7/2018
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D
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2000
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(1)
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12/21/2020
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Common Stock
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2000
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(2)
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0
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D
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Stock Option (Right-to-Buy)
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$3
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11/7/2018
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D
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2000
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(1)
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12/22/2021
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Common Stock
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2000
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(2)
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0
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D
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Stock Option (Right-to-Buy)
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$4.48
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11/7/2018
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D
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2000
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(1)
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12/20/2022
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Common Stock
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2000
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(2)
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0
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D
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Explanation of Responses:
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(1)
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Fully vested.
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(2)
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Pursuant to previously announced Agreement and Plan of Merger, dated September 5, 2018, by and among Polaris Industries Inc., Iceman Merger Sub, Inc. and WSI Industries, Inc., each outstanding option was cancelled in exchange for a cash payment in an amount equal to the excess, if any, of $7.00 over the share exercise price of such option multiplied by the number of shares of common stock subject to such option.
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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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Myers Burton F. II
222 SOUTH NINTH STREET, SUITE 3050
MINNEAPOLIS, MN 55402
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X
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Signatures
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Suzette McNally, Attorney-in-Fact for Burton F. Myers II
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11/7/2018
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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 4(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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