Statement of Changes in Beneficial Ownership (4)
November 20 2019 - 4:28PM
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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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
*
DANIELS MICHAEL E |
2. Issuer Name and Ticker or Trading Symbol
NICOLET BANKSHARES INC
[
NCBS
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner __X__ Officer (give title below) _____ Other (specify below) EVP and Secretary |
(Last)
(First)
(Middle)
C/O NICOLET NATIONAL BANK, 111 NORTH WASHINGTON STREET |
3. Date of Earliest Transaction
(MM/DD/YYYY)
11/18/2019 |
(Street)
GREEN BAY, WI 54301
(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 | 11/18/2019 | | M | | 13500 | A | $23.80 | 84353 | D | |
Common Stock | 11/18/2019 | | F | | 8761 | D | $70.50 | 75592 | D | |
Common Stock | 11/18/2019 | | M | | 40500 | A | $25.90 | 116092 | D | |
Common Stock | 11/18/2019 | | F | | 26921 | D | $70.50 | 89171 | D | |
Common Stock | 11/18/2019 | | S | | 10818 | D | $70.50 | 78353 | D | |
Common Stock | 11/18/2019 | | A | | 2712 | A | $70.50 | 81065 | D | |
Common Stock | 11/18/2019 | | F | | 425 | D | $70.50 | 80640 | D | |
Common Stock | 11/19/2019 | | G |
V
| 7500 (1) | D | $0 | 73140 (2) | D | |
Common Stock | | | | | | | | 6252 | I | By 401(k) Plan |
Common Stock | | | | | | | | 9803 | I | By Spouse |
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 |
Stock Option (Right to Buy) | $23.80 | 11/18/2019 | | M | | | 13500 | (3) | 10/28/2024 | Common Stock | 13500 | $0 | 0 | D | |
Stock Option (Right to Buy) | $25.90 | 11/18/2019 | | M | | | 40500 | (4) | 1/20/2025 | Common Stock | 40500 | $0 | 13500 | D | |
Stock Option (Right to Buy) | $70.50 | 11/18/2019 | | A | | 54000 | | (5) | 11/18/2029 | Common Stock | 54000 | $70.50 | 54000 | D | |
Explanation of Responses: |
(1) | Shares gifted to a Donor Advised Trust. |
(2) | Includes 186 shares acquired under the Employee Stock Purchase Plan to date. |
(3) | The nonqualified stock option is fully exercised. The options vested in five annual installments of 13,500 shares annually on October 28 of each year, beginning on October 28, 2015 and fully vested on October 28, 2019. |
(4) | The remaining 13,500 nonqualified options are not currently exercisable. The options vest in five annual installments of 13,500 shares annually on January 20 of each year, beginning on January 20, 2016 and fully vest on January 20, 2020. |
(5) | The nonqualified options vest in five annual installments of 10,800 shares on November 18 of each year, beginning on November 18, 2020 and will fully vest on November 18, 2024. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
DANIELS MICHAEL E C/O NICOLET NATIONAL BANK 111 NORTH WASHINGTON STREET GREEN BAY, WI 54301 | X |
| EVP and Secretary |
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Signatures
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/s/ Ann K. Lawson, as attorney-in-fact for Michael E. Daniels | | 11/20/2019 |
**Signature of Reporting Person | Date |
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