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)
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2. Date of Event Requiring Statement
(Month/Day/Year) 12/30/2005 |
3. Issuer Name and Ticker or Trading Symbol
Triple Crown Media, Inc. [ TCMI ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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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) |
Common Stock, par value $0.001 per share | 25,099(1) | D | |
Common Stock, par value $0.001 per share | 1,414(2) | D | |
Common Stock, par value $0.001 per share | 50(1) | I | As Custodian for Child |
Common Stock, par value $0.001 per share | 5,857(1) | I | By Spouse |
Common Stock, par value $0.001 per share | 6,875(3) | I | By Delta Fire and Casualty Insurance |
Common Stock, par value $0.001 per share | 2,101(2) | I | By Delta Fire and Casualty Insurance |
Common Stock, par value $0.001 per share | 22,170(4) | I | By Bankers Fidelity Ins. Co. |
Common Stock, par value $0.001 per share | 2,206(2) | I | By Bankers Fidelity Ins. Co. |
Common Stock, par value $0.001 per share | 13,835(5) | I | By Georgia Casualty & Surety Co. |
Common Stock, par value $0.001 per share | 1,772(2) | I | By Georgia Casualty & Surety Co. |
Common Stock, par value $0.001 per share | 14,579(6) | I | By Delta Life Insurance Co. |
Common Stock, par value $0.001 per share | 5,958(2) | I | By Delta Life Insurance Co. |
Common Stock, par value $0.001 per share | 9,700(7) | I | By Associated Casualty Insurance Co. |
Common Stock, par value $0.001 per share | 5,000(8) | I | By American Southern Insurance Company |
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 | ||||
Option (right to buy) | 12/30/2005 | 04/23/2006 | Common Stock, par value $0.001 per share | 216(9) | $843.43 | D |
Explanation of Responses: |
1. Represents the shares issued in the spin-off of Triple Crown Media, Inc. from Gray Television, Inc. (the "Spin-Off"). |
2. Received in exchange for shares of Bull Run Corporation common stock in the merger of Bull Run Corporation into BR Acquisition Corp., a direct, wholly-owned subsidiary of Triple Crown Media, Inc. (the "Merger"). |
3. Represents the shares issued to Delta Fire and Casualty Insurance in the Spin-Off. Mr. Howell is an officer and a director of Delta Fire and Casualty Insurance. |
4. Represents the shares issued to Bankers Fidelity Ins. Co. in the Spin-Off. Mr. Howell is an officer and a director of Bankers Fidelity Ins. Co. |
5. Represents the shares issued to Georgia Casualty and Surety Co. in the Spin-Off. Mr. Howell is an officer and a director of Georgia Casualty and Surety Co. |
6. Represents the shares issued to Delta Life Insurance Co. in the Spin-Off. Mr. Howell is an officer and a director of Delta Life Insurance Co. |
7. Represents the shares issued to Associated Casualty Insurance Co. in the Spin-Off. Mr. Howell is an officer and a director of Associated Casualty & Surety Co. |
8. Represents the shares issued to American Southern Insurance Company in the Spin-Off. Mr. Howell is an officer and a director of American Southern Insurance Company. |
9. Received in the Merger in exchange for options to purchase Bull Run Corporation common stock. |
/s/ Hilton H. Howell, Jr. | 12/30/2005 | |
** 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. |