Statement of Changes in Beneficial Ownership (4)
May 25 2021 - 4:04PM
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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3235-0287
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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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BALLOU ROGER H |
2. Issuer Name and Ticker or Trading Symbol
ALLIANCE DATA SYSTEMS CORP
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ADS
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5. 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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(Last)
(First)
(Middle)
3075 LOYALTY CIRCLE |
3. Date of Earliest Transaction
(MM/DD/YYYY)
5/24/2021 |
(Street)
COLUMBUS, OH 43219
(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
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock | 5/24/2021 | | J(1) | | 3178 | A | $117.915 | 19499 (3) | D | |
Common Stock | | | | | | | | 0 (1)(2) | I | By Roger H. Ballou 2020 Grantor Retained Annuity Trust |
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 |
Explanation of Responses: |
(1) | On May 24, 2021, the Reporting Person withdrew 3,178 shares of ADS common stock from the Roger H. Ballou 2020 Grantor Retained Annuity Trust. In exchange for the shares, the Reporting Person contributed cash in the amount of $374,733.87 to the trust. The withdrawal of shares from the trust resulted in a decrease in the number of shares the Reporting Person beneficially owns indirectly through the trust and a corresponding increase in the number of shares the Reporting Person beneficially owns directly. The Reporting Person believes that his withdrawal of shares from the trust constitutes a change in form of beneficial ownership of the shares, exempted by Rule 16a-13 under the Securities Exchange Act of 1934. |
(2) | On May 20, 2021, 322 shares of ADS common stock were distributed to the Reporting Person by the Roger H. Ballou 2020 Grantor Retained Annuity Trust. |
(3) | The total amount of securities beneficially owned includes: (a) 8,888 unrestricted shares; (b) 1,915 unvested restricted stock units granted 6/30/11; (c) 1,374 unvested restricted stock units granted 6/29/12; (d) 679 unvested restricted stock units granted 7/1/13; (e) 489 unvested restricted stock units granted 7/1/14; (f) 418 unvested restricted stock units granted 6/29/15; (g) 602 unvested restricted stock units granted 6/27/16; (h) 564 unvested restricted stock units granted 6/26/17; (i) 655 unvested restricted stock units granted 6/25/18; (j) 959 unvested restricted stock units granted 6/24/19; and (k) 2,956 unvested restricted stock units granted 6/22/20. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
BALLOU ROGER H 3075 LOYALTY CIRCLE COLUMBUS, OH 43219 | X |
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Signatures
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Cynthia L. Hageman, Attorney in Fact | | 5/25/2021 |
**Signature of Reporting Person | Date |
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