SEC Form 3
| FORM 3 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 08/13/2018 | 3. Issuer Name and Ticker or Trading Symbol Select Interior Concepts, Inc. [ SIC ] | |||||||||||||
| 4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
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| Table I - Non-Derivative Securities Beneficially Owned | |||
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| 1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
| Class A Common Stock | 104,368 | D | |
| Class A Common Stock | 32,018(1) | D | |
| Class A Common Stock | 128,074(2) | D | |
| Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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| 1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
| Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
| Phantom Stock | (3) | (3) | Class A Common Stock | 128,074 | (3) | D | |
| Explanation of Responses: |
| 1. These shares of Class A Common Stock were granted by the Issuer to the Reporting Person under the Issuer's 2017 Incentive Compensation Plan on November 22, 2017, and will vest in equal installments annually over three years, provided that the Reporting Person remains in the service of the Issuer through the applicable vesting date. |
| 2. These shares of Class A Common Stock were granted by the Issuer to the Reporting Person under the Issuer's 2017 Incentive Compensation Plan on November 22, 2017, and will vest in equal installments annually over three years upon the achievement by the Issuer of certain performance goals, provided that the Reporting Person remains in the service of the Issuer through the applicable vesting date. |
| 3. The phantom stock is economically equivalent to the Issuer's Class A Common Stock. These phantom stock were granted by the Issuer to the Reporting Person under the Issuer's 2017 Incentive Compensation Plan on November 22, 2017, and will vest upon the achievement by the Issuer of certain performance goals and be settled in cash on such vesting date, provided that the Reporting Person remains in the service of the Issuer through such vesting date. |
| Remarks: |
| /s/ Tyrone Johnson | 08/13/2018 | |
| ** Signature of Reporting Person | Date | |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
| * If the form is filed by more than one reporting person, see Instruction 5 (b)(v). | ||
| ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. | ||