5 1 0001.txt U.S. SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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(f) of the Investment Company Act of 1940 [_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). [_] Form 3 Holdings Reported [_] Form 4 Transactions Reported -------------------------------------------------------------------------------- 1. Name and Address of Reporting Person* Brown Jeffry R -------------------------------------------------------------------------------- (Last) (First) (Middle) 1285 Corporate Center Drive, Suite No. 175 -------------------------------------------------------------------------------- (Street) Eagan MN 55121 -------------------------------------------------------------------------------- (City) (State) (Zip) -------------------------------------------------------------------------------- 2. Issuer Name and Ticker or Trading Symbol Sac Technologies, Inc. (SACM) -------------------------------------------------------------------------------- 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) -------------------------------------------------------------------------------- 4. Statement for Month/Year December 31, 2000 -------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Year) -------------------------------------------------------------------------------- 6. Relationship of Reporting Person to Issuer (Check all applicable) [X] Director [_] 10% Owner [X] Officer (give title below) [_] Other (specify below) President -------------------------------------------------------------------------------- 7. Individual or Joint/Group Filing (Check applicable line) [X] Form filed by one Reporting Person [_] Form filed by more than one Reporting Person -------------------------------------------------------------------------------- ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================
5. 6. 4. Amount of Owner- Securities Acquired (A) or Securities ship Disposed of (D) Beneficially Form: 7. (Instr. 3, 4 and 5) Owned at End Direct Nature of 2. 3. ----------------------------- of Issuer's (D) or Indirect 1. Transaction Transaction (A) Fiscal Year Indirect Beneficial Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership (Instr. 3) (mm/dd/yy) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------
* If the form is filed by more than one Reporting Person, see Instruction 4(b)(v). Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Print or Type Responses) (Over) (Form 5-07/99) FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
9. 10. Number Owner- of ship 2. Deriv- of Conver- 5. 7. ative Deriv- 11. sion Number of Title and Amount Secur- ative Nature or Derivative 6. of Underlying 8. ities Secur- of Exer- Securities Date Securities Price Bene- ity: In- cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) ------------------------------------------------------------------------------------------------------------------------------------ Stock Options $.6875 11/13/00 A 280,000 (1) 11/13/07 Common 280,000 n/a (right to buy) Stock ------------------------------------------------------------------------------------------------------------------------------------ Non-Qualified $.6875 11/13/00 A 300,000 (2) 11/13/07 Common 300,000 n/a Stock Options Stock issued under the 1999 stock option plan (right to buy) ------------------------------------------------------------------------------------------------------------------------------------ 630,000 D n/a ====================================================================================================================================
Explanation of Responses: (1) Options to purchase 120,000 shares vested upon issuance and the remainder vest in monthly installment as follows: (i) 6,667 shares on December 1, 2000 and on the first day of each month thereafter terminating October 1, 2002; and (ii) 6,659 shares on November 1, 2002. (2) Options to purchase 60,000 shares vested upon issuance and the remainder vest in equal monthly installments of 20,000 shares per month commencing December 1, 2000. /s/ Jeffry R. Brown 2/14/01 --------------------------------------------- ----------------------- **Signature of Reporting Person Date ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). Note: File three copies of this form, one of which must be manually signed. If space provided is insufficient, see Instruction 6 for procedure. Page 2 Derivative Securities Codes (Except For Transactions Exempt Pursuant to Rule 16b-3) C--Conversion of derivative security E--Expiration of short derivative position H--Expiration (or cancellation) of long derivative position with value received O--Exercise of out-of-the-money derivative security X--Exercise of in-the-money or at-the-money derivative security Other Section 16(b) Exempt Transaction and Small Acquisition Codes (Except For Rule 16b-3 Codes Above) G--Bona fide gift L--Small acquisition under Rule 16a-6 W--Acquisition or disposition by will or the laws of descent and distribution Z--Deposit into or withdrawal from voting trust Other Transaction Codes J--Other acquisition or disposition (describe transaction) K--Transaction in equity swap or instrument with similar characteristics U--Disposition pursuant to a tender of shares in a change of control transaction To indicate that a holding should have been reported previously on Form 3, place a "3" in Table I, column 3 or Table II, column 4, as appropriate. Indicate in the space provided for explanation of responses the event triggering the Form 3 filing obligation. To indicate that a transaction should have been reported previously on Form 4, place a "4" next to the transaction code reported in Table I, column 3 or Table II, column 4 (e.g., an open market purchase of a non-derivative security that should have been reported previously on Form 4 should be designated as "P4"). To indicate that a transaction should have been reported on a previous Form 5, place a "5" in Table I, column 3 or Table II, column 4, as appropriate. In addition, the appropriate box on the front page of the form should be checked. FORM 3 OR FORM 4 HOLDINGS OR TRANSACTIONS NOT PREVIOUSLY REPORTED To indicate that a holding should have been reported previously on a Form 3, place a "3" in Table I, column 3 or Table II, column 4, as appropriate. Indicate in the space provided for explanation of responses the event triggering the Form 3 filing obligation. To indicate that a transaction should have been reported previously on Form 4, place a "4" next to the transaction code reported in Table I, column 3 or Table II, column 4 (e.g., an open market purchase of a non-derivative security that should have been reported previously on Form 4 should be designated as "P4"). In addition, the appropriate box on the front page of the form should be checked.