------------------------------------
OMB Number: 3235-0362
Expires: January 31, 2005
Estimated average burden hours per
response. . . 1.0
------------------------------------
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*
Bergman Stanley M.
- --------------------------------------------------------------------------------
(Last) (First) (Middle)
c/o Henry Schein, Inc.
135 Duryea Rd.
- --------------------------------------------------------------------------------
(Street)
Melville New York 11747
- --------------------------------------------------------------------------------
(City) (State) (Zip)
________________________________________________________________________________
2. Issuer Name and Ticker or Trading Symbol
Henry Schein, Inc. (HSIC)
________________________________________________________________________________
3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
________________________________________________________________________________
4. Statement for Month/Year
Fiscal year ended December 28, 2002
________________________________________________________________________________
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)
Chief Executive Officer and 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-
2A. Securities Acquired (A) or Securities ship
Deemed Disposed of (D) Beneficially Form: 7.
2. Execution (Instr. 3, 4 and 5) Owned at End Direct Nature of
Transaction Date, if 3. ----------------------------- of Issuer's (D) or Indirect
1. Date any Transaction (A) Fiscal Year Indirect Beneficial
Title of Security (Month/ (Month/ Code Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) Day/Year) Day/Year) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4)
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 8/19/02 G 15,000 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 8/27/02 G 30 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 8/30/02 G 10 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 9/26/02 G 12 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 11/7/02 G 920 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 11/7/02 G 460 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 11/7/02 G 460 D
- ------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
*If the form is filed by more than one Reporting Person, see Instruction
4(b)(v).
(Over)
SEC 2270 (9-02)
Page 1 of 3
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 3A. Derivative 6. of Underlying 8. ities Secur- of
Exer- Deemed Securities Date Securities Price Bene- ity: In-
cise 3. Execu- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- tion 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Date, if Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date any action (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship
Security Secur- Day/ Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
/s/ Stanley M. Bergman February 11, 2003
- --------------------------------------------- -----------------------
**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.
SEC 2270 (9-02)
Page 2 of 3
Attachment A to Form 5
Reporting Person: Bergman, Stanley M.
Issuer: Henry Schein, Inc. (HSIC)
Statement for fiscal year ended December 28, 2002
Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially
Owned
================================================================================
1. 2. 2A. 3. 4. 5. 6. 7.
Title of Trans- Deemed Trans- Securities Amount of Ownership Nature of Indirect
Security action Execution action Acquired Securities Form Direct(D) Beneficial
(Instr.3) Date Date, if Code (A) or Beneficially or Indirect Ownership
(Month/ any (Instr.8) Disposed Owned at end (I) (Instr. 4) (Instr. 4)
Date/ (Month/ of (D) of Issuer's
Year) Date/ (Instr. Fiscal Year
Year) 3, 4 (Instr. 3
and 5) and 4)
----------
(A)
Amount or Price
(D)
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 11/7/02 G 460 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 11/7/02 G 460 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 11/26/02 G 389 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 11/26/02 G 389 D
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 10,039 (D)
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 716,739 (I) (1)
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 19,660 (I) (2)
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 778 (I) (3)
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock 4,800 (I) (4)
- ------------------------------------------------------------------------------------------------------------------------------------
Explanation of Responses:
- ------------------------
(1) Represents shares held by Stanley M. Bergman's wife and Lawrence O. Sneag
as co-trustees of the Stanley M. Bergman Continuing Trust dated
September 14, 1994.
(2) Represents shares held by Lawrence O. Sneag, Stanley M. Bergman's wife or
his sons as trustees of trusts for the benefit of immediate family members
of Stanley M. Bergman or certain other persons, wherein Stanley M. Bergman
is the grantor.
(3) Represents shares held directly by Stanley M. Bergman's sons.
(4) Represents shares held by Mark E. Mlotek as custodian for certain family
members of Stanley M. Bergman.
Page 3 of 3
