Annual Statement of Changes in Beneficial Ownership (5)
February 14 2017 - 5:59PM
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
|
OMB APPROVAL
OMB Number:
3235-0362
Estimated average burden
hours per response...
1.0
|
|
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
|
|
1. Name and Address of Reporting Person
*
Hagerman Philip R
|
2. Issuer Name
and
Ticker or Trading Symbol
Diplomat Pharmacy, Inc. [DPLO]
|
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
Chairman and CEO
|
(Last)
(First)
(Middle)
4100 S. SAGINAW ST.
|
3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2016
|
(Street)
FLINT, MI 48507
(City)
(State)
(Zip)
|
4. If Amendment, Date Original Filed
(MM/DD/YYYY)
|
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
|
|
|
|
|
|
|
1499756
(1)
|
I
|
Philip R. Hagerman Revocable Trust
(2)
|
Common Stock
|
|
|
|
|
|
|
3891609
|
I
|
2007 Hagerman Family GST Trust
(3)
|
Common Stock
|
|
|
|
|
|
|
4450091
|
I
|
The JH GST Trust
(2)
|
Common Stock
|
|
|
|
|
|
|
1550876
|
I
|
2013 Irrev. Exempt Trust for Daughter
(3)
|
Common Stock
|
|
|
|
|
|
|
1550876
|
I
|
2013 Irrev. Exempt Trust for Son
(3)
|
Common Stock
|
|
|
|
|
|
|
1215293
|
I
|
2013 Irrev. Exempt Trust for Daughter
(2)
|
Common Stock
|
|
|
|
|
|
|
1371292
|
I
|
2013 Irrev. Exempt Trust for Daughter
(2)
|
Common Stock
|
|
|
|
|
|
|
313337
|
I
|
2014 Irrev. Exempt Trust for Son
(3)
|
Common Stock
|
|
|
|
|
|
|
313337
|
I
|
2014 Irrev. Exempt Trust for Daughter
(3)
|
Common Stock
|
|
|
|
|
|
|
313337
|
I
|
2014 Irrev. Exempt Trust for Daughter
(2)
|
Common Stock
|
|
|
|
|
|
|
313337
|
I
|
2014 Irrev. Exempt Trust for Daughter
(2)
|
Common Stock
|
8/24/2016
|
|
G
|
734513
|
D
|
$0
|
0
(1)
|
I
|
Philip Hagerman 2014 GRAT
(3)
|
Common Stock
|
8/24/2016
|
|
G
|
734513
|
D
|
$0
|
0
(4)
|
I
|
Jocelyn Hagerman 2014 GRAT
(2)
|
Common Stock
|
|
|
|
|
|
|
696659
(4)
|
I
|
Jocelyn Hagerman Living Trust
(3)
|
Common Stock
|
|
|
|
|
|
|
301212
|
I
|
Philip R. Hagerman Living Trust
(2)
|
Common Stock
|
|
|
|
|
|
|
263500
|
I
|
JH Marital Trust
(2)
|
Common Stock
|
|
|
|
|
|
|
272000
|
I
|
PH Marital Trust
(3)
|
Common Stock
|
|
|
|
|
|
|
394910
|
I
|
Irrevocable Trust for Son
|
Common Stock
|
|
|
|
|
|
|
394910
|
I
|
Irrevocable Trust for Daughter
|
Common Stock
|
8/24/2016
|
|
G
|
367256
|
A
|
$0
|
367256
(1)
(4)
|
I
|
Irrevocable Non-Exempt Trust for Son
|
Common Stock
|
8/24/2016
|
|
G
|
367256
|
A
|
$0
|
367256
(1)
(4)
|
I
|
Irrevocable Non-Exempt Trust for Daughter
|
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)
|
On July 8, 2016, 338,823 shares held by the Philip Hagerman 2014 GRAT ("PH GRAT") were transferred to the Philip R. Hagerman Revocable Trust, and upon termination of the PH GRAT on August 24, 2016, the remaining 734,513 shares were transferred to trusts established for the reporting person's four children.
|
(
2)
|
These shares are indirectly owned by Mr. Hagerman as the trustee of the Philip R. Hagerman Revocable Trust, the Philip R. Hagerman Living Trust, The JH GST Trust, the 2013 Irrevocable Exempt Trusts and 2014 Irrevocable Exempt Trusts for two daughters, the Jocelyn Hagerman 2014 GRAT and the JH Marital Trust.
|
(
3)
|
Jocelyn Hagerman is Mr. Hagerman's wife. These shares are indirectly owned by her as a trustee of the 2007 Hagerman Family GST Trust, the 2013 Irrevocable Exempt Trusts and 2014 Irrevocable Exempt Trusts for a son and daughter, the Philip Hagerman 2014 GRAT, the Jocelyn Hagerman Living Trust and the PH Marital Trust.
|
(
4)
|
On July 8, 2016, 338,823 shares held by the Jocelyn Hagerman 2014 GRAT ("JH GRAT") were transferred to the Jocelyn Hagerman Living Trust, and upon termination of the JH GRAT on August 24, 2016, the remaining 734,513 shares were transferred to trusts established for Mrs. Hagerman's four children.
|
Reporting Owners
|
Reporting Owner Name / Address
|
Relationships
|
Director
|
10% Owner
|
Officer
|
Other
|
Hagerman Philip R
4100 S. SAGINAW ST.
FLINT, MI 48507
|
X
|
X
|
Chairman and CEO
|
|
Signatures
|
Jeffrey H. Kuras, by Power of Attorney
|
|
2/14/2017
|
**
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.
|
Diplomat Pharmacy (NYSE:DPLO)
Historical Stock Chart
From Apr 2024 to May 2024
Diplomat Pharmacy (NYSE:DPLO)
Historical Stock Chart
From May 2023 to May 2024