Statement of Changes in Beneficial Ownership (4)
February 23 2021 - 09:25AM
Edgar (US Regulatory)
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
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OMB
APPROVAL
OMB Number: 3235-0287
Estimated average burden
hours per response... 0.5 |
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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 * Davis Mark
Burton |
2. Issuer Name and Ticker or Trading
Symbol TILE SHOP HOLDINGS, INC. [ TTSH ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)_____
Director _____
10% Owner
__X__ Officer (give title
below) _____ Other
(specify below)
VP Inv. Relations & CAO |
(Last)
(First)
(Middle)
C/O TILE SHOP HOLDINGS, INC., 14000 CARLSON
PARKWAY |
3. Date of Earliest Transaction (MM/DD/YYYY)
2/20/2021
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(Street)
PLYMOUTH, MN 55441
(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) |
Code |
V |
Amount |
(A) or (D) |
Price |
Common Stock |
2/20/2021 |
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F |
|
475 (1) |
D |
$6.50 |
81879 (2) |
D |
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Common Stock |
|
|
|
|
|
|
|
820 |
I |
By Child #1 |
Common Stock |
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|
|
|
|
|
|
775 |
I |
By Child #2 |
Common Stock |
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|
|
|
|
|
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765 |
I |
By Child #3 |
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 |
Stock Option (Right to Buy) |
$8.58 |
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|
|
|
|
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(3) |
10/21/2021 |
Common Stock |
20000 |
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20000 |
D |
|
Stock Option (Right to Buy) |
$14.19 |
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|
|
|
|
|
(3) |
7/14/2022 |
Common Stock |
2737 |
|
2737 |
D |
|
Stock Option (Right to Buy) |
$8.5 |
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|
|
|
|
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(4) |
11/6/2027 |
Common Stock |
5400 |
|
5400 |
D |
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Explanation of
Responses: |
(1) |
The reporting person has
elected to satisfy his tax withholding obligation in connection
with the vesting of a prior restricted stock grant by directing the
Issuer to withhold shares otherwise issuable upon vesting of the
previously reported grant. |
(2) |
Includes (i) 3,195 shares of
restricted stock for which the risks of forfeiture will lapse as to
1,597 shares on 2/20/22 and 1,598 shares on 2/20/23; (ii) 43,104
shares of restricted stock for which the risks of forfeiture will
lapse as to 14,368 shares on each of 10/23/21, 10/23/22 and
10/23/23; and (iii) 14,247 shares of restricted stock for which the
risks of forfeiture will lapse as to 3,562 shares on each of
3/16/21, 3/16/22 and 3/16/23 and 3,561 shares on
3/16/24. |
(3) |
Fully
exercisable. |
(4) |
Options to purchase 1,350
shares will vest on 11/6/2021. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
Davis Mark Burton
C/O TILE SHOP HOLDINGS, INC.
14000 CARLSON PARKWAY
PLYMOUTH, MN 55441 |
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|
VP Inv. Relations & CAO |
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Signatures
|
/s/ Mark Davis |
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2/23/2021 |
**Signature
of Reporting Person |
Date |