Statement of Changes in Beneficial Ownership (4)
June 16 2023 - 7:43PM
Edgar (US Regulatory)
FORM 4
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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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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
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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
*
Wijesuriya Dilantha |
2. Issuer Name and Ticker or Trading Symbol
ARC DOCUMENT SOLUTIONS, INC.
[
ARC
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director _____ 10% Owner __X__ Officer (give title below) _____ Other (specify below) President and COO |
(Last)
(First)
(Middle)
C/O ARC DOCUMENT SOLUTIONS, INC., 12657 ALCOSTA BLVD., SUITE 200 |
3. Date of Earliest Transaction
(MM/DD/YYYY)
3/7/2017 |
(Street)
SAN RAMON, CA 94583 |
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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(City)
(State)
(Zip)
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Rule 10b5-1(c) Transaction Indication
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Check this box to indicate that a transaction was made pursuant to a contract, instruction or written plan that is intended to
satisfy the affirmative defense conditions of Rule 10b5-1(c). See Instruction 10.
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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 | 3/7/2017 (1) | | G | | 10441 (2) | D | $0 | 98334 | D | |
Common Stock | 3/7/2017 (1) | | G | | 10441 (2) | A | $0 | 338891 | I | Wijesuriya Family Trust DTD 9/4/2002 |
Common Stock | 9/10/2021 (1) | | G | | 161524 (2) | D | $0 | 233335 | D | |
Common Stock | 9/10/2021 (1) | | G | | 161524 (2) | A | $0 | 500415 | I | Wijesuriya Family Trust DTD 9/4/2002 |
Common Stock | 2/23/2022 (1) | | G | | 19943 (2) | D | $0 | 235001 | D | |
Common Stock | 2/23/2022 (1) | | G | | 19943 (2) | A | $0 | 520358 | I | Wijesuriya Family Trust DTD 9/4/2002 |
Common Stock | 12/27/2022 (1) | | G | | 56314 (2) | D | $0 | 168335 | D | |
Common Stock | 12/27/2022 (1) | | G | | 56314 (2) | A | $0 | 576672 | I | Wijesuriya Family Trust DTD 9/4/2002 |
Common Stock | 2/27/2023 (1) | | G | | 6808 (2) | D | $0 | 198577 | D | |
Common Stock | 2/27/2023 (1) | | G | | 6808 (2) | A | $0 | 583480 | I | Wijesuriya Family Trust DTD 9/4/2002 |
Common Stock | 3/9/2023 (1) | | G | | 6908 (2) | D | $0 | 191669 | D | |
Common Stock | 3/9/2023 (1) | | G | | 6908 (2) | A | $0 | 590388 | I | Wijesuriya Family Trust DTD 9/4/2002 |
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 |
Explanation of Responses: |
(1) | Between March 7, 2017 and March 9, 2023 (the "Applicable Period"), the reporting person made transfers (the "Transfers") to The Wijesuriya Revocable Family Trust dated September 4, 2002 (the "Trust"). The Transfers were inadvertently not previously reported. The beneficial ownership balances reported in this Form 4 reflect the amounts beneficially owned by the reporting person and the Trust on such dates during the Applicable Period. |
(2) | Gift of shares to the Trust, Dilantha Wijesuriya and Manjoa Wijesuriya as Trustees. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Wijesuriya Dilantha C/O ARC DOCUMENT SOLUTIONS, INC. 12657 ALCOSTA BLVD., SUITE 200 SAN RAMON, CA 94583 |
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| President and COO |
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Signatures
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/s/ Jorge Avalos, Attorney-in-Fact | | 6/16/2023 |
**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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