- Annual Statement of Changes in Beneficial Ownership (5)
November 12 2010 - 4:33PM
Edgar (US Regulatory)
FORM 5
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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Form 3 Holdings Reported
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Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0362
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February 28, 2011
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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(f) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
HILLENBRAND W AUGUST
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2. Issuer Name
and
Ticker or Trading Symbol
Hill-Rom Holdings, Inc. [HRC]
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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)
1069 STATE ROUTE 46 EAST
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
9/30/2010
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(Street)
BATESVILLE, IN 47006
(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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Amount
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(A) or (D)
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Price
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Common Stock
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11/18/2009
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G
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2827
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D
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(1)
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131450
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D
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Common Stock
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11/19/2009
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G
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1112
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D
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(1)
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130338
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D
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Common Stock
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1/7/2010
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G
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2080
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D
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(1)
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128258
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D
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Common Stock
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1/8/2010
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G
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68
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D
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(1)
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128190
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D
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Common Stock
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1/20/2010
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G
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165
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D
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(1)
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80726
(2)
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D
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Common Stock
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14405
(3)
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I
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By Spouse
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Common Stock
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34529
(3)
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I
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By Spouse's GRAT
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Common Stock
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71773
(4)
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I
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By Family LLC GRAT
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Common Stock
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715400
(4)
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I
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By Various Trusts
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Common Stock
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361598
(5)
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I
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By Various GRATs
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Common Stock
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0
(2)
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I
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By W August Hillenbrand 2003 Option GRAT
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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(A)
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(D)
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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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Explanation of Responses:
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(
1)
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Price - Not Applicable
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(
2)
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This amount reflects distributions of shares of common stock to and from the beneficiaries of GRATs by the Reporting Person. Each such distribution qualifies as only a change in the form of Reporting Person's beneficial ownership, and, as such, has not been previously reported.
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(
3)
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These amounts reflect the distribution of shares of common stock as annuity payment from GRATs to Reporting Person's Spouse. Such distribution qualifies as only a change in the form of the Reporting Person's beneficial ownership, and, as such, has not been previously reported.
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(
4)
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Reporting person disclaims beneficial ownership of these securities.
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(
5)
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This amount reflects the distribution of shares of common stock to and from these GRATs. Each such distribution qualifies as only a change in the form of the Reporting Person's beneficial ownership, and, as such, has not been previously reported.
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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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HILLENBRAND W AUGUST
1069 STATE ROUTE 46 EAST
BATESVILLE, IN 47006
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X
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Signatures
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/s/ Marcia Riehle, Attorney-in-fact
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11/12/2010
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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 4(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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