Statement of Changes in Beneficial Ownership (4)
May 18 2023 - 3:22PM
Edgar (US Regulatory)
FORM 4
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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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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WEYERS ROBERT J |
2. Issuer Name and Ticker or Trading Symbol
NICOLET BANKSHARES INC
[
NIC
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
C/O NICOLET NATIONAL BANK, 111 NORTH WASHINGTON STREET |
3. Date of Earliest Transaction
(MM/DD/YYYY)
5/16/2023 |
(Street)
GREEN BAY, WI 54301 |
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
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(City)
(State)
(Zip)
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Rule 10b5-1(c) Transaction Indication
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Check this box to indicate that a transaction was made pursuant to a contract, instruction or written plan that is intended to
satisfy the affirmative defense conditions of Rule 10b5-1(c). See Instruction 10.
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock | 5/16/2023 | | A | | 898 (1) | A | $55.65 | 88613 | D | |
Common Stock | | | | | | | | 3500 | I | by RJW Family Investments LLC (2) |
Common Stock | | | | | | | | 4000 | I | By Ronald and Colleen Weyers Grandchildren's Trust #2 (3) |
Common Stock | | | | | | | | 25250 | I | By Weyers Family Limited Partnership (4) |
Common Stock | | | | | | | | 8605 | I | By Nicolet National Bank Deferred Compensation Plan For Non-employee Directors |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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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 |
Explanation of Responses: |
(1) | The Company paid Mr. Weyers the Board annual retainer, granted as a restricted stock award with an immediate full vest of 898 shares, as of May 16, 2023. |
(2) | Represents the holdings of RJW Family Investments, LLC of which the reporting person is an owner. The reporting person disclaims beneficial ownership of registrant common stock held by RJW Family Investments, LLC except to the extent of his pecuniary interest. |
(3) | Represents the holdings of Ronald and Colleen Weyers Grandchildren's Trust #2 of which the reporting person is trustee. The reporting person disclaims beneficial ownership of registrant common stock held by Ronald and Colleen Weyers Grandchildren's Trust #2 except to the extent of his pecuniary interest. |
(4) | Represents the holdings of Weyers Family Limited Partnership, of which the reporting person is a general partner. The reporting person disclaims beneficial ownership of registrant common stock held by Weyers Family Limited Partnership except to the extent of his pecuniary interest. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
WEYERS ROBERT J C/O NICOLET NATIONAL BANK 111 NORTH WASHINGTON STREET GREEN BAY, WI 54301 | X |
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Signatures
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/s/ H. Phillip Moore, Jr., as attorney-in-fact for Robert J. Weyers | | 5/18/2023 |
**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. |
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