SEC FORM
3
SEC Form 3
| FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
01/01/2004
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3. Issuer Name and Ticker or Trading Symbol
LILLY ELI & CO
[ LLY ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
|
10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| President, US Operations |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
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 |
50,788 |
D |
|
| Common Stock |
1,144 |
I |
401(k) |
| Common Stock |
2,070 |
I
|
by daughter |
| Common Stock |
2,070 |
I
|
by son |
| Common Stock |
2,292 |
I
|
by wife |
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
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: 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 |
Expiration Date |
Title |
Amount or Number of Shares |
| Employee stock option (right to buy) |
04/21/1997 |
04/20/2004 |
Common Stock |
15,880 |
12.3125 |
D |
|
| Employee stock option (right to buy) |
10/17/1997 |
10/15/2004 |
Common Stock |
16,000 |
14.6575 |
D |
|
| Employee stock option (right to buy) |
10/16/1998 |
10/14/2005 |
Common Stock |
27,728 |
23.4075 |
D |
|
| Employee stock option (right to buy) |
10/21/1999 |
10/20/2006 |
Common Stock |
13,110 |
34.595 |
D |
|
| Employee stock option (right to buy) |
10/20/2000 |
10/19/2007 |
Common Stock |
20,000 |
64.06 |
D |
|
| Employee stock option (right to buy) |
10/19/1998 |
10/17/2008 |
Common Stock |
25,000 |
74.2813 |
D |
|
| Employee Stock Option (right to buy) |
10/18/2002 |
10/16/2009 |
Common Stock |
46,000 |
66.375 |
D |
|
| Employee stock option (right to buy) |
02/20/2004 |
02/18/2011 |
Common Stock |
50,600 |
73.98 |
D |
|
| Employee stock option (right to buy) |
10/05/2004 |
10/04/2011 |
Common Stock |
23,000 |
79.28 |
D |
|
| Employee stock option (right to buy) |
02/19/2005 |
02/17/2012 |
Common Stock |
46,000 |
75.92 |
D |
|
| Employee stock option (right to buy) |
02/17/2006 |
02/15/2013 |
Common Stock |
50,000 |
57.85 |
D |
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| Explanation of Responses: |
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| Remarks: |
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|
Gino Santini |
01/12/2004 |
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** Signature of Reporting Person |
Date |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
| * If the form is filed by more than one reporting person,
see
Instruction
5
(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). |
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
| 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 Number. |
Gino Santini
Lilly Corporate Center
Indianapolis, Indiana 46285
Securities and Exchange Commission
Washington, D.C. 20549
Authorization Regarding Reporting Forms
I hereby authorize and designate the following persons to
sign and file with the Commission on my behalf Forms 4 and
5 covering my transactions and holdings in the common stock
and other equity securities of Eli Lilly and Company as required
by Section 16 of the Securities Exchange Act of 1934 and the rules
thereunder:
Alecia A. DeCoudreaux, Lilly Corporate Center, Indianapolis, Indiana
James B. Lootens, Lilly Corporate Center, Indianapolis, Indiana
Bronwen L. Mantlo, Lilly Corporate Center, Indianapolis, Indiana
This authorization and designation shall remain in effect until
a written revocation is signed by me and provided to the Commission.
Date: January 8, 2004
Gino Santini
