SEC Form 4 · accession 0001367859-18-000109
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
Sep 28, 2018
Accepted (ET)
Sep 28, 2018 · 6:54 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 shareF1,F2 | Sep 28, 2018 | C | 19,230 | — | A | 49,230 | I | By IRA |
| Common Stock, par value $.01 per shareF1,F3 | Sep 28, 2018 | C | 8,460 | — | A | 8,460 | I | By Roth IRA |
| Common Stock, par value $.01 per shareF4 | holding | — | — | — | 3,980 | I | By James & Patricia Lang Grandchildren Education Trust | |
| Common Stock, par value $.01 per shareF5 | holding | — | — | — | 2,500 | I | By Leah Delaney Karge Trust | |
| Common Stock, par value $.01 per share | holding | — | — | — | 515 | D |
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 StockF2,F1 | — | Sep 28, 2018 | C | 1,923 | D | — | — | Common Stock | 19,230 | 0 | I |
| Series A Preferred StockF3,F1 | — | Sep 28, 2018 | C | 846 | D | — | — | Common Stock | 8,460 | 0 | I |
Explanation of responses
- F1Each share of 8% Series A Mandatorily Convertible Non-Cumulative Non-Voting Perpetual Stock was mandatorily converted into ten (10) shares of the Company's common stock three days following stockholder approval of the issuance of the underlying common stock and had no expiration date.
- F2These shares are held in the reporting person's self-directed IRA.
- F3These shares are held in the reporting person's self-directed Roth IRA.
- F4These 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.
- F5These 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.