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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction 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 (Month/Day/Year) |
7. Title and Amount of Underlying Securities (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) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Stock Appreciation Rights (2) | $ 18.45 | 09/14/2015 | M | 25,001 | (3) | 12/18/2022 | Common Stock | 25,001 | $ 0 | 49,999 | D | ||||
Stock Appreciation Rights (2) | $ 22.13 | 09/14/2015 | M | 25,001 | (3) | 12/18/2022 | Common Stock | 25,001 | $ 0 | 49,999 | D | ||||
Stock Appreciation Rights (2) | $ 26.56 | 09/14/2015 | M | 25,001 | (3) | 12/18/2022 | Common Stock | 25,001 | $ 0 | 49,999 | D | ||||
Stock Appreciation Rights (2) | $ 31.87 | 09/14/2015 | M | 25,001 | (3) | 12/18/2022 | Common Stock | 25,001 | $ 0 | 49,999 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Cleveland Todd M 107 W. FRANKLIN ELKHART, IN 46515 |
X | President & CEO |
/s/ Todd M. Cleveland by Andy Nemeth, Attorney-in-Fact | 09/16/2015 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | Reflects exercise of the stock appreciation rights reported on Table II of this Form 4. |
(2) | Reflects a stock appreciation right that was granted on December 18, 2013. Amounts set forth in this Form 4 have been adjusted to reflect Patrick Industries, Inc.'s stock dividend of one share of common stock for every two shares held of outstanding common stock paid on May 29, 2015. |
(3) | The shares exercised on September 14, 2015 became exercisable on December 18, 2014. 24,999 additional shares become exercisable on December 18, 2015 and 25,000 additional shares will become exercisable on December 18, 2016. |