Amended Statement of Beneficial Ownership (3/a)
September 15 2022 - 1:04PM
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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3235-0104
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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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JOHNSON BRENDA L |
2. Date of Event Requiring Statement (MM/DD/YYYY)
8/26/2022
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3. Issuer Name and Ticker or Trading Symbol
NICOLET BANKSHARES INC [NIC]
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(Last)
(First)
(Middle)
C/O NICOLET NATIONAL BANK, 111 N. WASHINGTON STREET |
4. 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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(Street)
GREEN BAY, WI 54301
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY) 8/30/2022
| 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) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 30906 (1) | D | |
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) | 2. Date Exercisable and Expiration Date (MM/DD/YYYY) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) |
Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
(1) | This report on Form 3/A amends the original Form 3 filed by Ms. Johnson on August 30, 2022. These shares were omitted from Ms. Johnson's original Form 3, and omitted from one Form 4 filing on August 30, 2022 related to the merger consideration Ms. Johnson received after the original Form 3 was filed. This Form 3/A report is being filed to correct Ms. Johnson's Nicolet Bankshares, Inc. direct beneficial ownership total prior to the Charter Bankshares, Inc. and Nicolet Bankshares, Inc. merger, effective August 26, 2022. Ms. Johnson's total beneficial ownership in Nicolet Bankshares, Inc. as of the date of this report is 669,965 shares. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
JOHNSON BRENDA L C/O NICOLET NATIONAL BANK 111 N. 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 Brenda L. Johnson | | 9/15/2022 |
**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 5(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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