SEC Form 5 · accession 0000914190-18-000030
TILE SHOP HOLDINGS, INC. · TTS
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Robert A Rucker
Officer — Interim CEO · Director · 10% Owner
Period of report
Dec 31, 2017
Accepted (ET)
Feb 14, 2018 · 5:30 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001552800
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common Stock | Jul 27, 2017 | G | 15,600 | $0.00 | D | 240,825 | D | |
| Common Stock | Jul 27, 2017 | G | 1,950 | $0.00 | A | 3,380 | I | By Spouse |
| Common Stock | Jul 27, 2017 | G | 1,950 | $0.00 | A | 3,380 | I | By UGMA #1 |
| Common Stock | Jul 27, 2017 | G | 1,950 | $0.00 | A | 3,380 | I | By UGMA #2 |
| Common Stock | Jul 27, 2017 | G | 1,950 | $0.00 | A | 3,380 | I | By UGMA #3 |
| Common Stock | Jul 27, 2017 | G | 1,950 | $0.00 | A | 3,380 | I | By UGMA #4 |
| Common Stock | Jul 27, 2017 | G | 1,950 | $0.00 | A | 3,380 | I | By UGMA #5 |
| Common Stock | Jul 27, 2017 | G | 1,950 | $0.00 | A | 3,380 | I | By UGMA #6 |
| Common Stock | Jul 27, 2017 | G | 1,950 | $0.00 | A | 3,380 | I | By UGMA #7 |
| Common Stock | Oct 13, 2017 | G | 2,300,000 | $0.00 | D | 500,000 | I | By 2016 Grantor Retained Annuity Trust |
| Common StockF2 | Oct 13, 2017 | G | 2,300,000 | $0.00 | A | 4,952,428 | I | By The Tile Shop, Inc. |
| Common StockF2 | Oct 13, 2017 | G | 2,000,000 | $0.00 | D | 2,952,428 | I | By The Tile Shop, Inc. |
| Common Stock | Oct 13, 2017 | G | 2,000,000 | $0.00 | A | 2,000,000 | I | By 2017 Grantor Retained Annuity Trust |
| Common StockF1 | Dec 12, 2017 | G | 9,000 | $0.00 | D | 231,825 | D | |
| Common StockF2 | Dec 15, 2017 | G | 2,300,000 | $0.00 | D | 652,428 | I | By The Tile Shop, Inc. |
| Common Stock | Dec 15, 2017 | G | 2,300,000 | $0.00 | A | 2,300,000 | I | By 2017 Grantor Retained Annuity Trust II |
Table II — derivative securities
No Table II lines on this filing.
Explanation of responses
- F1Includes 5,038 shares of restricted stock granted pursuant to the Company's 2012 Omnibus Award Plan, which are subject to a purchase option in favor of the Company until the earlier of (a) the date of the Company's next annual meeting of stockholders and (2) July 13, 2018.
- F2These securities are owned by The Tile Shop, Inc. ("TS, Inc."). The reporting person is the sole officer and member of the board of directors of TS, Inc., holds sole voting and dispositive power over the securities held by TS, Inc., and may be deemed to beneficially own the securities held by TS, Inc..