SEC Form 4 · accession 0001367859-18-000071
Citizens Community Bancorp Inc. · CZWI
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
James R Lang
Director
Period of report
Jun 20, 2018
Accepted (ET)
Jun 21, 2018 · 5:40 pm EDT
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001367859
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common Stock, par value $.01 per share | holding | — | — | — | 515 | D | ||
| Common Stock, par value $.01 per shareF1 | holding | — | — | — | 30,000 | I | By IRA | |
| Common Stock, par value $.01 per shareF2 | holding | — | — | — | 3,980 | I | By James & Patricia Lang Grandchildren Education Trust | |
| Common Stock, par value $.01 per shareF3 | holding | — | — | — | 2,500 | I | By Leah Delaney Karge Trust |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Series A Preferred StockF1,F4 | — | Jun 20, 2018 | A | 1,923 | A | — | — | Common Stock | 19,230 | 1,923 | I |
| Series A Preferred StockF5,F4 | — | Jun 20, 2018 | A | 846 | A | — | — | Common Stock | 8,460 | 846 | I |
Explanation of responses
- F1These shares are held in the reporting person's self-directed IRA.
- F2These shares are held by the James & Patricia Lang Grandchildren Education Trust UAD 01/01/2002, pursuant to which Mr. Lang serves as an investment manager and has investment discretion over such shares. Mr. Lang disclaims beneficial ownership of these shares except to the extent of his pecuniary interest therein.
- F3These shares are held by the Leah Delaney Karge Trust pursuant to which Mr. Lang serves as trustee and has investment discretion. Mr. Lang disclaims beneficial ownership of these shares except to the extent of his pecuniary interest therein.
- F4Each share of 8.00% Series A Mandatorily Convertible Non-Cumulative Non-Voting Perpetual Preferred Stock is mandatorily convertible into ten shares of the Company's common stock upon stockholder approval of the issuance of the underlying common stock and has no expiration date.
- F5These shares are held in the reporting person's self-directed Roth IRA.