SEC Form 4 · accession 0001470254-15-000007

Unique Fabricating, Inc. · UFAB

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

Reporting owner

10% Owner

Period of report

Sep 21, 2015

Accepted (ET)

Sep 23, 2015 · 1:35 pm EDT

Rule 10b5-1 plan

unknown — predates the checkbox

Issuer CIK

0001617669

Table I — non-derivative securities

Security	Date	Code	Shares	Price	A/D	Owned after	D/I	Nature of ownership
Common Stock	holding	—	—		—	1,444,632	D

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Stock Option (Right to Buy)^F3,F4,F2	$12.50	Sep 21, 2015	J	7,500	A	Aug 17, 2015	Aug 17, 2025	Common Stock	7,500	7,500	I

F1By James Illikman as agent of The Peninsula Fund V Limited Partnership (the "Fund").
F2The stock option vested as to 20% of the shares as of the date of the grant; the option will vest as to 20% of the shares on each of the first, second, third and fourth anniversaries of the grant.
F3The Fund is the beneficial owner of 100% of the subject securities.
F4The subject securities were granted to Mr. Illikman in consideration for his service as a director of the issuer. The Fund acquired beneficial ownership of the securities via letter agreement with James Illikman dated September 21, 2015. Pursuant to the letter agreement, Mr. Illikman agreed to assign any profits recognized upon exercise of the options and sale of the underlying securities to the Fund, in consideration for his employment by the Fund and his nomination by the Fund to serve as a member of the issuer's board of directors. Pursuant to the letter agreement, the Fund also has the authority to direct Mr. Illikman with regard to the exercise of the options and the disposition of the underlying securities in a manner consistent with the NQO award agreement by which they were granted.