SEC Form 4 · accession 0001179110-17-012319
SUPREME INDUSTRIES INC · STS
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Peter D Barrett
Director
Period of report
Sep 6, 2017
Accepted (ET)
Sep 14, 2017 · 9:33 pm EDT
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0000350846
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Class A Common StockF2,F3,F4 | Sep 6, 2017 | J | 26,700 | $0.00 | A | 26,700 | I | By Trust |
| Class A Common StockF5,F2,F3,F4 | Sep 6, 2017 | J | 26,700 | $0.00 | D | 0 | I | By Trust |
| Class A Common StockF6,F3,F4 | holding | — | — | — | 33,321 | D | ||
| Class B Common StockF7,F3,F4 | holding | — | — | — | 29,467 | D |
Table II — derivative securities
No Table II lines on this filing.
Explanation of responses
- F1Represents shares of Class A common stock of Supreme Industries, Inc., par value $0.10 per share ("Class A Shares"), that were ultimately received in connection with a distribution by an independently controlled limited liability company to its members.
- F2Represents Class A Shares held directly by the Peter D. Barrett 2012 Irrevocable Trust (the "Trust"). Peter D. Barrett is the trustee and beneficiary of, and may be deemed to beneficially own securities held by, the Trust.
- F3This statement is filed by and on behalf of Peter D. Barrett. Mr. Barrett and the Trust are the direct beneficial owners of the securities covered by this statement.
- F4The reporting person states that neither the filing of this statement nor anything herein shall be deemed an admission that such person is, for purposes of Section 16 of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), or otherwise, the beneficial owner of any securities covered by this statement. The reporting person disclaims beneficial ownership of the securities covered by this statement, except to the extent of the pecuniary interest of such person in such securities.
- F5Represents Class A Shares that were distributed by the Trust to Mr. Barrett, as the sole beneficiary of the Trust (the "Trust Distribution").
- F6Includes all 26,700 Class A Shares that were distributed by the Trust to Mr. Barrett in connection with the Trust Distribution. The acquisition of such Class A Shares by Mr. Barrett in connection with the Trust Distribution constituted a change in the form of beneficial ownership without a change in pecuniary interest that is exempt from Section 16 of the Exchange Act pursuant to Rule 16a-13 thereunder. Rule 16a-9(a) under the Exchange Act may also exempt the acquisition of such Class A Shares by Mr. Barrett in connection with the Trust Distribution from Section 16 of the Exchange Act.
- F7Represents shares of Class B common stock of Supreme Industries, Inc., par value $0.10 per share ("Class B Shares"). Class B Shares are freely convertible on a one-to-one basis into an equal number of Class A Shares.