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