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*
King Timothy P

(Last) (First) (Middle)
3075 LOYALTY CIRCLE

(Street)
COLUMBUS OH 43219

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
06/05/2019
3. Issuer Name and Ticker or Trading Symbol
ALLIANCE DATA SYSTEMS CORP [ ADS ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
EVP & Chief Financial Officer
5. 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 Beneficially Owned
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 11,967.752(1) D
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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
Explanation of Responses:
1. The total number of securities beneficially owned includes: (a) 3,755.752 unrestricted shares; (b) 245 unvested units from an award of 720 time-based restricted stock units granted 2/15/17, which are scheduled to vest on 2/18/20; (c) 684 unvested units from an award of 2,010 performance-based restricted stock units granted 2/15/17, which are scheduled to vest on 2/18/20; (d) 475 unvested units from an award of 708 time-based restricted stock units granted 2/15/18, of which 234 units will vest on 2/18/20 and 241 units will vest on 2/16/21; (e) 1,439 unvested units from an award of 2,147 performance-based restricted stock units granted 2/15/18, of which 709 units will vest on 2/18/20 and 730 units will vest on 2/16/21; (f) 1,073 unvested time-based restricted stock units granted 2/15/19, of which 354 units will vest on each of 2/18/20 and 2/16/21 and 365 units will vest on 2/15/22; (continued below)
Remarks:
(1) continued from above: and (g) 4,296 unvested performance-based restricted stock units granted 2/15/19, which may be adjusted up or down at the time the performance restriction lapses. The restriction may lapse with respect to 33% of such shares on each of 2/18/20 and 2/16/21 and with respect to 34% of such shares on 2/15/22 contingent on meeting an EBT metric for 2019 and subject to continued employment by the Reporting Person on the vesting dates.
Cynthia L. Hageman, Attorney in Fact 06/13/2019
** 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.
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