Annual Statement of Changes in Beneficial Ownership (5)
February 16 2021 - 03:47PM
Edgar (US Regulatory)
FORM 5
[ ]
Check this 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
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL
OWNERSHIP OF SECURITIES
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OMB Number: 3235-0362
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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 * Howell Robin
Robinson |
2. Issuer Name and Ticker or Trading
SymbolATLANTIC AMERICAN CORP [AAME] |
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)
4370 PEACHTREE ROAD, N.E. |
3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2020
|
(Street)
ATLANTA, GA 30319
(City)
(State)
(Zip)
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4. 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 |
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) |
Amount |
(A) or (D) |
Price |
Common Stock |
2/27/2020 |
|
G |
1025 |
D |
$0 |
21900 |
D |
|
Common Stock |
|
|
|
|
|
|
61956 (1) |
I |
Custodian For Children |
Common Stock |
2/27/2020 |
|
G |
1025 |
A |
$0 |
3954281 (2) |
I |
Trust Beneficiary |
Common Stock |
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|
|
|
|
|
2175 |
I |
By IRA Account |
Common Stock |
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|
|
|
|
|
809884 (3) |
I |
By Spouse |
Common Stock |
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|
|
|
|
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358556 (4) |
I |
Trust F/B/O Children |
Table II - Derivative Securities Acquired, Disposed of, or
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
(MM/DD/YYYY) |
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 at End of Issuer's Fiscal Year
(Instr. 4) |
10. Ownership Form of Derivative Security: Direct
(D) or Indirect (I)
(Instr. 4) |
11. Nature of Indirect Beneficial Ownership
(Instr. 4) |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Explanation of
Responses: |
(1) |
Mrs. Howell disclaims
beneficial ownership of all such shares. |
(2) |
Beneficiary under trust
holding shares for her benefit and over which her mother, Harriett
J. Robinson, is trustee. |
(3) |
Mrs. Howell has an indirect
interest in the following shares of Common Stock owned by her
husband, Hilton H. Howell, Jr.: 535,940 shares owned directly and
273,944 shares owned through his 401(k) plan. Mrs. Howell disclaims
beneficial ownership of all such shares. |
(4) |
Shares held in a trust for
the benefit of Mrs. Howell's children and over which her mother
serves as trustee. Mrs. Howell disclaims beneficial ownership of
all such shares. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
Howell Robin Robinson
4370 PEACHTREE ROAD, N.E.
ATLANTA, GA 30319 |
X |
|
|
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Signatures
|
Robin R. Howell |
|
2/16/2021 |
**Signature of Reporting
Person |
Date |