SEC Form 4
FORM 4 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

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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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
1. Name and Address of Reporting Person*
QUINN JEFFRY N

(Last) (First) (Middle)
12935 N. FORTY DRIVE, SUITE 201

(Street)
ST. LOUIS MO 63141

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Jason Industries, Inc. [ JASN ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
Officer (give title below) X Other (specify below)
Chairman of the Board
3. Date of Earliest Transaction (Month/Day/Year)
08/24/2015
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction 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)
Code V Amount (A) or (D) Price
Common Stock 06/10/2015 G V 34,257(1) D $0.00 15,743 I See footnote(7)(8)
Common Stock 08/24/2015 J(2) 15,743 D $4.81 0 I See footnote(7)(8)
Common Stock 97,560(3) D
Common Stock 06/10/2015 G V 34,000(1) D $0.00 3,736,955(4) I See footnote(7)(8)
Common Stock 08/24/2015 J(2) 15,743 A $4.81 3,752,698(5) I See footnote(7)(8)
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction 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 (Month/Day/Year) 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 Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Warrants $12 08/14/2014 06/30/2019 Common Stock 532,551 532,551(6) I See footnote(7)(8)
Explanation of Responses:
1. On June 10, 2015, the Jeffry N. Quinn Revocable Trust dated July 28, 2000, as amended, and The Quinn Group gifted shares as part of a charitable contribution.
2. For estate planning purposes, on August 24, 2015, 15,743 shares of Jason Industries, Inc. common stock were sold by the Jeffry N. Quinn Revocable Trust dated July 28, 2000, as amended, to the Jeffry N. Quinn Family Trust uad 8/10/2012 FBO Grace Quinn and to the Jeffry N. Quinn Family Trust uad 8/10/2012 FBO Sarah Quinn.
3. Includes 97,560 shares held by Jeffry Quinn, IRA.
4. The balance has been updated to correct an overstatement of the securities beneficially owned by The Quinn Group and the Jeffry N. Quinn Family Trusts uad 8/10/2012 included in the Reporting Person's Form 4 filed on September 23, 2014.
5. Includes 3,700,285 shares held by The Quinn Group, 26,207 shares held by the Jeffry N. Quinn Family Trust uad 8/10/2012 FBO Grace Quinn and 26,206 shares held by the Jeffry N. Quinn Family Trust uad 8/10/2012 FBO Sarah Quinn.
6. Includes 522,551 warrants held by The Quinn Group, 5,000 warrants held by the Jeffry N. Quinn Family Trust uad 8/10/2012 FBO Grace Quinn and 5,000 warrants held by the Jeffry N. Quinn Family Trust uad 8/10/2012 FBO Sarah Quinn.
7. Jeffry N. Quinn maintains control over the securities beneficially owned by the Jeffry N. Quinn Revocable Trust dated July 28, 2000, as amended, The Quinn Group, the Jeffry N. Quinn Family Trust uad 8/10/2012 FBO Grace Quinn and the Jeffry N. Quinn Family Trust uad 8/10/2012 FBO Sarah Quinn, and, consequently, Mr. Quinn may be deemed to be the beneficial owner of such securities.
8. The Reporting Person disclaims beneficial ownership except to the extent of its 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.
Remarks:
Exhibit 24 - Power of Attorney
/s/ William P. Schultz as attorney-in-fact 08/26/2015
** 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 4 (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).
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