Statement of Changes in Beneficial Ownership (4)
July 02 2019 - 4:33PM
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).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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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
*
Hyman James E
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2. Issuer Name
and
Ticker or Trading Symbol
Jason Industries, Inc.
[
JASN
]
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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)
833 EAST MICHIGAN STREET, SUITE 900
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3. Date of Earliest Transaction
(MM/DD/YYYY)
7/1/2019
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(Street)
MILWAUKEE, WI 53202
(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
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15000
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I
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Nicholas Hyman Irrevocable Trust
(1)
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Common Stock
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15000
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I
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Eloise Madeline Hyman Irrevocable Trust
(1)
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Common Stock
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15000
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I
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Katharine Laura Susannah Hyman Irrevocable Trust
(1)
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Common Stock
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33000
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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. 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
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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 Following Reported Transaction(s) (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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Code
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V
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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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Restricted Stock Units
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(2)
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7/1/2019
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A
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40000
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(2)
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(2)
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Common Stock
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40000.0
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$0
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117630
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D
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Explanation of Responses:
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(1)
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The Reporting Person maintains certain influence over the securities beneficially owned by the Trust. The Reporting Person disclaims beneficial ownership except to the extent of its pecuniary interest therein, and this report shall not be deemed an admission that such Reporting Person is the beneficial owner of the securities for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or for any other purpose.
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(2)
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The restricted stock units vest on the one (1) year anniversary of the applicable grant date, assuming continued service. The board of directors or applicable committee of the board may, in its sole discretion, provide for accelerated vesting of the restricted stock units at any time and for any reason. Subject to the board or board committee's discretion to accelerate vesting, all unvested restricted stock units shall be immediately forfeited upon the reporting person's termination of service for any reason. Additionally, all restricted stock units shall become fully vested upon the occurrence of a change of control of Jason Industries, Inc., provided that the reporting person has not been terminated prior to such change of control. Vested restricted stock units will settle in the form of shares of common stock, cash or a combination thereof on the date that is six (6) months following the date of termination of service.
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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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Hyman James E
833 EAST MICHIGAN STREET
SUITE 900
MILWAUKEE, WI 53202
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X
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Signatures
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/s/ James M. Reeves as attorney-in-fact
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7/2/2019
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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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