Annual Statement of Changes in Beneficial Ownership (5)
February 13 2023 - 03:41PM
Edgar (US Regulatory)
FORM 5
[ ] Check this box if no longer subject to Section
16. Form 4 or Form 5 obligations may continue. See
Instruction 1(b).
[ ] Form 3 Holdings Reported
[ ] Form 4 Transactions Reported |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL
OWNERSHIP OF SECURITIES
|
OMB APPROVAL
OMB Number: 3235-0362
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hours per response... 1.0 |
|
Filed pursuant to Section 16(a) of the
Securities Exchange Act of 1934 or Section 30(h) of the Investment
Company Act of 1940
|
|
1. Name
and Address of Reporting Person * Howell Robin
Robinson |
2. Issuer Name and Ticker or Trading
SymbolATLANTIC AMERICAN CORP [AAME] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)__X__
Director _____
10% Owner
_____ Officer (give title
below) _____ Other
(specify below)
|
(Last)
(First)
(Middle)
4370 PEACHTREE ROAD, N.E. |
3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2022
|
(Street)
ATLANTA, GA 30319
(City)
(State)
(Zip)
|
4. If Amendment, Date Original
Filed(MM/DD/YYYY)
|
6. Individual or Joint/Group
Filing(Check Applicable Line)
_X_ Form Filed by One Reporting Person
___ Form Filed by More than One Reporting Person |
Table I - Non-Derivative Securities Acquired, Disposed of, or
Beneficially Owned
|
1.Title of Security
(Instr. 3) |
2. Trans. Date |
2A. Deemed Execution Date, if any |
3. Trans. Code
(Instr. 8) |
4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5) |
5. Amount of Securities Beneficially Owned Following
Reported Transaction(s)
(Instr. 3 and 4) |
6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4) |
7. Nature of Indirect Beneficial Ownership
(Instr. 4) |
Amount |
(A) or (D) |
Price |
Common Stock |
|
|
|
|
|
|
31900 |
D |
|
Common Stock |
5/1/2022 |
|
J (1) |
30368 |
D(1) |
$0.00 |
0 |
I |
Custodian For Children |
Common Stock |
|
|
|
|
|
|
3954281 (2) |
I |
Trust Beneficiary |
Common Stock |
|
|
|
|
|
|
2175 |
I |
By IRA Account |
Common Stock |
|
|
|
|
|
|
826318 (3) |
I |
By Spouse |
Common Stock |
|
|
|
|
|
|
408765 (4) |
I |
Trust F/B/O Children |
Table II - Derivative Securities Acquired, Disposed of, or
Beneficially Owned (e.g., puts, calls, warrants, options,
convertible securities)
|
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
(MM/DD/YYYY) |
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 at End of Issuer's Fiscal Year
(Instr. 4) |
10. Ownership Form of Derivative Security: Direct
(D) or Indirect (I)
(Instr. 4) |
11. Nature of Indirect Beneficial Ownership
(Instr. 4) |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Explanation of
Responses: |
(1) |
Represents a disposition of
30,368 shares formerly held by Mrs. Howell as custodian for the
benefit of her children. On the transaction date, the shares were
transferred to the individual holdings of the adult
children. |
(2) |
Beneficiary under trust
holding shares for her benefit and over which her mother, Harriett
J. Robinson, is trustee. |
(3) |
Mrs. Howell has an indirect
interest in the following shares of Common Stock owned by her
husband, Hilton H. Howell, Jr.: 517,272 shares owned directly and
309,046 shares owned through his 401(k) plan. Mrs. Howell disclaims
beneficial ownership of all such shares. |
(4) |
Shares held in a trust for
the benefit of Mrs. Howell's children and over which her mother
serves as trustee. Mrs. Howell disclaims beneficial ownership of
all such shares. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
Howell Robin Robinson
4370 PEACHTREE ROAD, N.E.
ATLANTA, GA 30319 |
X |
|
|
|
Signatures
|
/s/ Robin R. Howell |
|
2/13/2023 |
**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 4(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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