0001104659-21-094500.txt : 20210721 0001104659-21-094500.hdr.sgml : 20210721 20210721173305 ACCESSION NUMBER: 0001104659-21-094500 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210720 FILED AS OF DATE: 20210721 DATE AS OF CHANGE: 20210721 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: 211105381 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 tm2122874-2_4seq1.xml OWNERSHIP DOCUMENT X0306 4 2021-07-20 0 0001552800 TILE SHOP HOLDINGS, INC. TTSH 0001555194 JACULLO PETER J III C/O TILE SHOP HOLDINGS, INC. 14000 CARLSON PARKWAY PLYMOUTH MN 55441 1 0 1 0 Common Stock 2021-07-20 4 A 0 14477 0 A 473210 D Common Stock 4441180 I By JWTS, Inc. Common Stock 3676989 I By Irrevocable Trust Represents 14,477 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 20, 2022. 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 co-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/ Mark Davis as Attorney-in-Fact for Peter J. Jacullo III pursuant to Power of Attorney 2021-07-21