Annual Statement of Changes in Beneficial Ownership (5)
February 13 2023 - 03:41PM
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 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0362
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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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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)
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(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
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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) | 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)
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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 (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
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Howell Robin Robinson 4370 PEACHTREE ROAD, N.E. ATLANTA, GA 30319 | X |
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Signatures
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/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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