0001104659-20-006873.txt : 20200124
0001104659-20-006873.hdr.sgml : 20200124
20200124203959
ACCESSION NUMBER: 0001104659-20-006873
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20200115
FILED AS OF DATE: 20200124
DATE AS OF CHANGE: 20200124
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: RUCKER ROBERT A
CENTRAL INDEX KEY: 0001555206
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35629
FILM NUMBER: 20546915
MAIL ADDRESS:
STREET 1: 14000 CARLSON PARKWAY
CITY: PLYMOUTH
STATE: MN
ZIP: 55441
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: TILE SHOP, INC.
CENTRAL INDEX KEY: 0001555223
STATE OF INCORPORATION: MN
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35629
FILM NUMBER: 20546916
BUSINESS ADDRESS:
STREET 1: 14000 CARLSON PARKWAY
CITY: PLYMOUTH
STATE: MN
ZIP: 55441
BUSINESS PHONE: 763-852-2978
MAIL ADDRESS:
STREET 1: 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
tv536910_4.xml
OWNERSHIP DOCUMENT
X0306
4
2020-01-15
0
0001552800
TILE SHOP HOLDINGS, INC.
TTSH
0001555206
RUCKER ROBERT A
C/O TILE SHOP HOLDINGS, INC.
14000 CARLSON PARKWAY
PLYMOUTH
MN
55441
1
0
1
0
0001555223
TILE SHOP, INC.
C/O TILE SHOP HOLDINGS, INC.
14000 CARLSON PARKWAY
PLYMOUTH
MN
55441
0
0
1
1
Affiliate of Director
Common Stock
2020-01-15
5
G
0
E
515000
0
D
0
I
By 2017 Grantor Retained Annuity Trust II
Common Stock
2020-01-15
5
G
0
E
515000
0
A
2952428
I
By The Tile Shop, Inc.
Common Stock
2020-01-17
5
G
0
E
2500000
0
D
0
I
By 2018 Grantor Retained Annuity Trust II
Common Stock
2020-01-17
5
G
0
E
2500000
0
A
5452428
I
By The Tile Shop, Inc.
Common Stock
75596
D
Common Stock
3380
I
By Spouse
Common Stock
3380
I
By UGMA #1
Common Stock
3380
I
By UGMA #2
Common Stock
3380
I
By UGMA #3
Common Stock
3380
I
By UGMA #4
Common Stock
3380
I
By UGMA #5
Common Stock
3380
I
By UGMA #6
Common Stock
3380
I
By UGMA #7
Includes 24,571 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 16, 2020.
These securities are owned by The Tile Shop, Inc. Mr. Rucker is the sole director of The Tile Shop, Inc. Mr. Rucker 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 Mr. Rucker is the beneficial owner of such securities for Section 16 or any other purpose.
Transfers for no consideration pursuant to the terms of the respective GRAT.
/s/ Robert A. Rucker
2020-01-24
THE TILE SHOP, INC. /s/ Robert A. Rucker, President
2020-01-24