Initial Statement of Beneficial Ownership (3)
September 05 2014 - 2:31PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
Estimated average burden
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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
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Sampson L Heath
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2. Date of Event Requiring Statement (MM/DD/YYYY)
8/27/2014
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3. Issuer Name
and
Ticker or Trading Symbol
Advanced Emissions Solutions, Inc. [ADES]
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(Last)
(First)
(Middle)
9135 S RIDGELINE BLVD STE 200
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
_____ 10% Owner
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X
___ Officer (give title below)
_____ Other (specify below)
CFO and Treasurer /
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(Street)
HIGHLANDS RANCH, CO 80129
(City)
(State)
(Zip)
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5. 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 Beneficially Owned
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1.Title of Security
(Instr. 4)
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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
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12289
(1)
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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. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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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 of Derivative Security: 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
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Expiration Date
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Title
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Amount or Number of Shares
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Performance Share Units
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(2)
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(2)
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Common Stock
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8932
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(3)
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D
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Explanation of Responses:
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(
1)
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Represents Restricted Stock (common stock subject to certain repurchase rights) issued pursuant to the Advanced Emissions Solutions, Inc. Amended and Restated 2007 Equity Incentive Plan, as amended (the "2007 Plan"). Of such amount, 7,823 shares will vest, if at all, on August 27, 2015 and one-third of the remaining 4,466 shares will vest, if at all, on each of January 2, 2015, January 2, 2016 and January 2, 2017. Vesting of the Restricted Stock is subject to Mr. Sampson's continuous service with Advanced Emissions Solutions, Inc. or its related entities unless such shares vest sooner pursuant to Section 11 of the 2007 Plan or Mr. Sampson's employment agreement.
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(
2)
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Vesting of the Performance Share Units, if at all, will occur on January 2, 2017, subject to Mr. Sampson's continuous service with the Issuer or its related entities and the achievement of certain pre-established goals to be measured as of December 31, 2016, unless such units vest sooner at the target amount pursuant to Section 11 of the 2007 Plan or Mr. Sampson's employment agreement.
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(
3)
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Each Performance Share Unit represents a contingent right to receive one share of the Issuer's common stock.
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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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Sampson L Heath
9135 S RIDGELINE BLVD STE 200
HIGHLANDS RANCH, CO 80129
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CFO and Treasurer
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Signatures
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L. Heath Sampson
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9/5/2014
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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 5(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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