Initial Statement of Beneficial Ownership (3)
September 13 2019 - 4:18PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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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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Davis Mark Burton |
2. Date of Event Requiring Statement (MM/DD/YYYY)
9/6/2019
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3. Issuer Name and Ticker or Trading Symbol
TILE SHOP HOLDINGS, INC. [TTS]
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(Last)
(First)
(Middle)
C/O TILE SHOP HOLDINGS, INC., 14000 CARLSON PARKWAY |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) VP Inv. Relations & CAO / |
(Street)
PLYMOUTH, MN 55441
(City)
(State)
(Zip)
| 5. 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 Beneficially Owned
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1.Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 15490 (1) | D | |
Common Stock | 820 | I | By Child #1 |
Common Stock | 775 | I | By Child #2 |
Common Stock | 765 | I | By Child #3 |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 4) | 2. Date Exercisable and Expiration Date (MM/DD/YYYY) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) |
Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Stock Option (Right to Buy) | (2) | 10/21/2021 | Common Stock | 20000 | $8.58 | D | |
Stock Option (Right to Buy) | (3) | 7/14/2022 | Common Stock | 2737 | $14.19 | D | |
Stock Option (Right to Buy) | (4) | 11/2/2027 | Common Stock | 5400 | $8.50 | D | |
Explanation of Responses: |
(1) | Includes 6,390 shares of restricted stock for which the risks of forfeiture will lapse as to 1,598 shares on each of 2/20/20 and 2/20/21 and as to 1,597 shares on each of 2/20/22 and 2/20/23. |
(2) | Options to purchase 4,000 shares vest on each of 10/21/15, 10/21/16, 10/21/17, 10/21/18 and 10/21/19. |
(3) | Options to purchase 548 shares vest on each of 7/14/16 and 7/14/17 and options to purchase 547 shares vest on each of 7/14/18, 7/14/19 and 7/14/20. |
(4) | Option to purchase 1,350 shares vest on each of 11/2/18, 11/2/19, 11/2/20 and 11/2/21. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Davis Mark Burton C/O TILE SHOP HOLDINGS, INC. 14000 CARLSON PARKWAY PLYMOUTH, MN 55441 |
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| VP Inv. Relations & CAO |
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Signatures
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/s/ Amanda Lorentz as Attorney-in-Fact for Mark Burton Davis pursuant to Power of Attorney filed herewith. | | 9/13/2019 |
**Signature of Reporting Person | Date |
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