0000914190-19-000200.txt : 20190606 0000914190-19-000200.hdr.sgml : 20190606 20190606175843 ACCESSION NUMBER: 0000914190-19-000200 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20190604 FILED AS OF DATE: 20190606 DATE AS OF CHANGE: 20190606 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: JACULLO PETER J III CENTRAL INDEX KEY: 0001555194 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35629 FILM NUMBER: 19883629 MAIL ADDRESS: STREET 1: C/O THE TILE SHOP, INC. STREET 2: 14000 CARLSON PARKWAY CITY: PLYMOUTH STATE: MN ZIP: 55441 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: TILE SHOP HOLDINGS, INC. CENTRAL INDEX KEY: 0001552800 STANDARD INDUSTRIAL CLASSIFICATION: RETAIL-HOME FURNITURE, FURNISHINGS & EQUIPMENT STORES [5700] IRS NUMBER: 455538095 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 14000 CARLSON PARKWAY CITY: PLYMOUTH STATE: MN ZIP: 55441 BUSINESS PHONE: 763-852-2950 MAIL ADDRESS: STREET 1: 14000 CARLSON PARKWAY CITY: PLYMOUTH STATE: MN ZIP: 55441 4 1 edgar.xml PRIMARY DOCUMENT X0306 4 2019-06-04 0001552800 TILE SHOP HOLDINGS, INC. TTS 0001555194 JACULLO PETER J III C/O TILE SHOP HOLDINGS, INC. 14000 CARLSON PARKWAY PLYMOUTH MN 55441 1 0 1 0 Common Stock 362262 D Common Stock 4441180 I By JWTS, Inc. Common Stock 2019-06-04 4 P 0 10000 4.18 A 1074424 I By Irrevocable Trust Common Stock 2019-06-04 4 P 0 2590 4.14 A 1077014 I By Irrevocable Trust Common Stock 2019-06-04 4 P 0 7410 4.23 A 1084424 I By Irrevocable Trust Common Stock 2019-06-05 4 P 0 10000 4.14 A 1094424 I By Irrevocable Trust Common Stock 2019-06-05 4 P 0 10000 4.09 A 1104424 I By Irrevocable Trust Common Stock 2019-06-05 4 P 0 10000 4.00 A 1114424 I By Irrevocable Trust Common Stock 2019-06-06 4 P 0 10000 3.95 A 1124424 I By Irrevocable Trust Common Stock 2019-06-06 4 P 0 10000 3.90 A 1134424 I By Irrevocable Trust Common Stock 2019-06-06 4 P 0 10000 3.85 A 1144424 I By Irrevocable Trust Includes 12,669 shares of restricted stock granted pursuant to the Company's 2012 Omnibus Award Plan, which are subject to a risk of forfeiture until the earlier of (a) the date of the Company's next annual meeting of stockholders and (b) July 10, 2019. These securities are owned by JWTS, Inc. The reporting person is the sole director of JWTS, Inc. The reporting person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein, and this report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for Section 16 or any other purpose. These securities are owned by the Katherine D. Jacullo Children's 1993 Irrevocable Trust. The reporting person is the trustee. The reporting person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein, and this report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for Section 16 or any other purpose. /s/ Amanda Lorentz as Attorney-in-Fact for Peter J. Jacullo III pursuant to Power of Attorney previously filed. 2019-06-06