Amended Statement of Beneficial Ownership (3/a)
September 15 2015 - 04:33PM
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
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
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1. Name and Address of Reporting Person
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LAWRENCE JEFFREY D
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2. Date of Event Requiring Statement (MM/DD/YYYY)
8/28/2015
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3. Issuer Name
and
Ticker or Trading Symbol
DOMINOS PIZZA INC [DPZ]
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(Last)
(First)
(Middle)
30 FRANK LLOYD WRIGHT DR
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
_____ 10% Owner
___
X
___ Officer (give title below)
_____ Other (specify below)
Chief Financial Officer /
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(Street)
ANN ARBOR, MI 48105
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
9/1/2015
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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, $0.01 par value
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15694.478
(1)
(2)
(3)
(4)
(5)
(6)
(7)
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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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Explanation of Responses:
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(
1)
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This amendment is being filed to correct a clerical error in the original Form 3.
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(
2)
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Includes 823.345 shares acquired under the Domino's Employee Stock Payroll Deduction Plan.
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(
3)
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Includes 890 shares of common stock representing two-fourths of an original grant of performance-based restricted stock that shall vest one-half on each of July 17, 2016 and July 17, 2017 if applicable performance conditions are achieved.
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(
4)
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Includes 1,060 shares of common stock representing two-fourths of an original grant of performance-based restricted stock that shall vest one-half on each of February 27, 2016 and February 27, 2017 if applicable performance conditions are achieved.
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(
5)
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Includes 1,133 shares of common stock representing three-fourths of an original grant of performance-based restricted stock that shall vest one-third on each of July 16, 2016, July 16, 2017 and July 16, 2018 if applicable performance conditions are achieved.
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(
6)
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Includes 960 shares of common stock representing a grant of performance-based restricted stock that shall vest one-fourth on each of July 15, 2016, July 15, 2017, July 15, 2018 and July 15, 2019 if applicable performance conditions are achieved.
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(
7)
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Includes 2,110 shares of common stock representing a grant of performance-based restricted stock that shall vest one-fourth on each of July 15, 2016, July 15, 2017, July 15, 2018 and July 15, 2019 if applicable performance conditions are achieved.
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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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LAWRENCE JEFFREY D
30 FRANK LLOYD WRIGHT DR
ANN ARBOR, MI 48105
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Chief Financial Officer
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Signatures
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/s/ Adam J. Gacek, attorney-in-fact
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9/15/2015
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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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