Statement of Changes in Beneficial Ownership (4)

Date : 03/23/2017 @ 8:09AM
Source : Edgar (US Regulatory)
Stock : Adcare Health Systems (GA) (delisted) (ADK)
Quote : 0.91  0.0 (0.00%) @ 2:05AM
Adcare Health Systems (GA) (delisted) share price Chart

Statement of Changes in Beneficial Ownership (4)

FORM 4
[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).         
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
                                                                                  
OMB APPROVAL
OMB Number: 3235-0287
Estimated average burden
hours per response...
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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
                      

1. Name and Address of Reporting Person *

Fox Michael J
2. Issuer Name and Ticker or Trading Symbol

ADCARE HEALTH SYSTEMS, INC [ ADK ]
5. Relationship of Reporting Person(s) to Issuer (Check all applicable)

__ X __ Director                      _____ 10% Owner
_____ Officer (give title below)      _____ Other (specify below)
(Last)          (First)          (Middle)

C/O PARK CITY CAPITAL, LLC, 200 CRESCENT COURT, SUITE 1575
3. Date of Earliest Transaction (MM/DD/YYYY)

1/9/2017
(Street)

DALLAS, TX 75201
(City)        (State)        (Zip)
4. If Amendment, Date Original Filed (MM/DD/YYYY)

 
6. Individual or Joint/Group Filing (Check Applicable Line)

___ Form filed by One Reporting Person
_ X _ Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1.Title of Security
(Instr. 3)
2. Trans. Date 2A. Deemed Execution Date, if any 3. Trans. Code
(Instr. 8)
4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V Amount (A) or (D) Price

Table II - Derivative Securities Beneficially Owned ( e.g. , puts, calls, warrants, options, convertible securities)
1. Title of Derivate Security
(Instr. 3)
2. Conversion or Exercise Price of Derivative Security 3. Trans. Date 3A. Deemed Execution Date, if any 4. Trans. Code
(Instr. 8)
5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
6. Date Exercisable and Expiration Date 7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
8. Price of Derivative Security
(Instr. 5)
9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
10% Convertible Subordinated Notes Due April 30, 2017     (1) 1/9/2017     J   (1)       $1000000    4/30/2015   4/30/2017   Common Stock   235294   (1) (2)   (1) 0   I   By Park City Capital, LLC  

Explanation of Responses:
( 1)  On January 9, 2017, the Company's cash tender offer for its outstanding 10% Convertible Subordinated Notes Due April 30, 2017 (the "Convertible Notes") at a purchase price equal to $1,000 per $1,000 principal amount of Convertible Notes purchased, plus accrued and unpaid interest on such Convertible Notes up to, but not including, the payment date, expired. The Company accepted for payment all of the Convertible Notes validly tendered. The Reporting Persons tendered all of their Convertible Notes held by Park City Capital Offshore Master, Ltd., the principal amount of which was convertible (at a conversion price equal to $4.25 per share) into 235,294 shares of the Company's common stock, to the Company.
( 2)  As the managing member of Park City Capital, LLC, Mr. Fox may be deemed to have beneficial ownership of the securities held by Park City Capital Offshore Master, Ltd. and Park City Special Opportunity Fund, LP, with respect to which Park City Capital, LLC, the investment manager to the funds, may be deemed to have beneficial ownership.

Reporting Owners
Reporting Owner Name / Address
Relationships
Director 10% Owner Officer Other
Fox Michael J
C/O PARK CITY CAPITAL, LLC
200 CRESCENT COURT, SUITE 1575
DALLAS, TX 75201
X


Park City Capital, LLC
200 CRESCENT COURT, SUITE 1575
DALLAS, TX 75201
X



Signatures
/s/ Michael J. Fox 3/23/2017
** Signature of Reporting Person Date

PARK CITY CAPITAL, LLC /s/Michael J. Fox Manager 3/23/2017
** 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 4(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 control number.

Adcare Health Systems (GA) (delisted) (AMEX:ADK)
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