0001104659-23-071694.txt : 20230615
0001104659-23-071694.hdr.sgml : 20230615
20230615174615
ACCESSION NUMBER: 0001104659-23-071694
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20230613
FILED AS OF DATE: 20230615
DATE AS OF CHANGE: 20230615
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: 231018695
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
tm2318831-3_4seq1.xml
OWNERSHIP DOCUMENT
X0407
4
2023-06-13
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
0
Common Stock
2023-06-13
4
A
0
20131
4.9677
A
515030
D
Common Stock
3191180
I
By JWTS, Inc.
Common Stock
4706489
I
By Irrevocable Trust
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.
Represents shares of restricted stock granted pursuant to the Company's 2021 Omnibus Equity Compensation 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) June 13, 2024.
/s/ Mark Davis as Attorney-in-Fact for Peter J. Jacullo III pursuant to Power of Attorney
2023-06-15