Annual Statement of Changes in Beneficial Ownership (5)
11 Février 2022 - 10:14PM
Edgar (US Regulatory)
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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Form 3 Holdings Reported
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Form 4 Transactions Reported
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
Andretta Ralph J | 2. Issuer Name and Ticker or Trading SymbolALLIANCE DATA SYSTEMS CORP [ADS] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner __X__ Officer (give title below) _____ Other (specify below) President and CEO |
(Last)
(First)
(Middle)
3095 LOYALTY CIRCLE | 3. Statement for Issuer's Fiscal Year Ended (MM/DD/YYYY) 12/31/2021 |
(Street)
COLUMBUS, OH 43219
(City)
(State)
(Zip)
| 4. If Amendment, Date Original Filed(MM/DD/YYYY) | 6. Individual or Joint/Group Filing(Check Applicable Line)
_X_ Form Filed by One Reporting Person
___ Form Filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3) | 2. Trans. Date | 2A. Deemed Execution Date, if any | 3. Trans. Code (Instr. 8) | 4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) |
Amount | (A) or (D) | Price |
Common Stock | | | | | | | 166547 (1)(2) | D | |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (MM/DD/YYYY) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year (Instr. 4) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) |
(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
(1) | In connection with the spin-off of Loyalty Ventures Inc. by the Issuer, outstanding unvested restricted stock units ("RSUs"), including RSUs previously granted to the Reporting Person, were subject to anti-dilution adjustments ("Anti-Dilution Adjustment"). To the extent that the outstanding RSUs granted to the Reporting Person were previously reported under Table I, the total number of shares reported include the additional RSUs held by the Reporting Person as a result of the Anti-Dilution Adjustment. |
(2) | Includes: (a) 10,558 unrestricted shares; (b) 5,311 unvested units from an award of 7,563 (adjusted from 6,827) time-based restricted stock units granted 2/18/20; (c) 4,795 unvested units from an award of 6,829 (adjusted from 6,165) time-based restricted stock units granted 2/18/20; (d) 8,827 unvested units from an award of 16,430 (adjusted from 15,207) time-based restricted stock units granted 2/18/20; (e) 14,263 (adjusted from 12,288) unvested performance-based restricted stock units granted 2/18/20; (f) 3,186 unvested units from an award of 4,538 (adjusted from 4,097) performance-based restricted stock units granted 2/18/20; (g) 14,336 unvested units from an award of 20,419 (adjusted from 18,434) performance-based restricted stock units granted 2/18/20; (h) 65,795 (adjusted from 56,684) unvested time-based restricted stock units granted 2/16/21; and (i) 39,476 (adjusted from 34,010) unvested performance-based restricted stock units granted 2/16/21. |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Andretta Ralph J 3095 LOYALTY CIRCLE COLUMBUS, OH 43219 | X |
| President and CEO |
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Signatures
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Benjamin L. Morgan, Attorney in Fact | | 2/11/2022 |
**Signature of Reporting Person | Date |
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