Initial Statement of Beneficial Ownership (3)
January 31 2018 - 6:05PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
Estimated average burden
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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
*
Kennedy Phillip B.
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2. Date of Event Requiring Statement (MM/DD/YYYY)
1/30/2018
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3. Issuer Name
and
Ticker or Trading Symbol
XERIUM TECHNOLOGIES INC [XRM]
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(Last)
(First)
(Middle)
C/O XERIUM TECHNOLOGIES, INC., 14101 CAPITAL BOULEVARD
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
_____ 10% Owner
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X
___ Officer (give title below)
_____ Other (specify below)
EVP, GC & Secretary /
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(Street)
YOUNGSVILLE, NC 27596
(City)
(State)
(Zip)
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5. 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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Table I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Common Stock
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40
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D
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Phantom Stock Unit
(1)
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(1)
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(1)
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Common Stock
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18222.0
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$0.0
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D
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Explanation of Responses:
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(1)
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These Phantom Stock Units were awarded on 5/30/17 in connection with the reporting person's participation in the 2017-2019 Long-Term Incentive Plan of Xerium Technologies, Inc. Each Phantom Stock Unit is the economic equivalent of one share of Xerium Technologies, Inc. common stock. Subject to time and performance conditions and early vesting in limited circumstances, on 5/30/2020, the Phantom Stock Units will be settled in cash equal to the average closing price of the common stock for the 30-days preceding 5/30/2020. No shares of common stock will be issued in connection with the settlement of the Phantom Stock Units.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Kennedy Phillip B.
C/O XERIUM TECHNOLOGIES, INC.
14101 CAPITAL BOULEVARD
YOUNGSVILLE, NC 27596
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EVP, GC & Secretary
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Signatures
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/s/ Phillip Kennedy
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1/31/2018
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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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