SEC Form 3 · accession 0001579252-16-000143

Jason Industries, Inc. · JASN

Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗

Reporting owner

Officer — See Remarks.

Period of report

Jan 19, 2016

Accepted (ET)

Jan 29, 2016 · 4:43 pm EST

Rule 10b5-1 plan

unknown — predates the checkbox

Issuer CIK

0001579252

Table I — non-derivative securities

Security	Date	Code	Shares	Price	A/D	Owned after	D/I	Nature of ownership
Common Stock^F1,F2,F3	holding	—	—		—	343,027	I	See footnote
Common Stock^F4	holding	—	—		—	8,000	I	By IRA

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Warrants^F2,F3,F5	$12.00	holding	—	—	—	Aug 14, 2014	Jun 30, 2019	Common Stock	53,833	—	I

F1Includes 324,692 shares held by the Allen Craig Ivey Revocable Living Trust Dated May 18, 2010 and 18,335 shares held by the Revocable Living Trust Agreement of Maxine M. Ivey.
F2The reporting person maintains control over the securities beneficially owned by the Allen Craig Ivey Revocable Living Trust Dated May 18, 2010 and the Revocable Living Trust Agreement of Maxine M. Ivey, and, consequently, the reporting person may be deemed to be the beneficial owner of such securities.
F3The reporting person disclaims beneficial ownership except to the extent of his pecuniary interest therein, and this report shall not be deemed an admission that such reporting person is the beneficial owner of the securities for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or for any other purpose.
F4Held by Allen Craig Ivey Roth IRA.
F5Includes 48,833 warrants held by the Allen Craig Ivey Revocable Living Trust Dated May 18, 2010 and 5,000 warrants held by the Revocable Living Trust Agreement of Maxine M. Ivey.

Interim President and Chief Operating Officer