0001144204-12-068520.txt : 20121218 0001144204-12-068520.hdr.sgml : 20121218 20121218181130 ACCESSION NUMBER: 0001144204-12-068520 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20121218 FILED AS OF DATE: 20121218 DATE AS OF CHANGE: 20121218 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: 763-852-2978 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: 121272560 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 4 1 form455769_20121218060940-.xml X0306 4 2012-12-18 0 0001552800 TILE SHOP HOLDINGS, INC. TTS 0001555223 TILE SHOP, INC. C/O TILE SHOP HOLDINGS, INC. 14000 CARLSON PARKWAY PLYMOUTH MN US 55441 0 0 1 1 Affiliate of Director Common Stock 2012-12-18 4 S 0 1183818 14.175 D 7129974 D Robert A. Rucker is the sole director of the reporting person and exercises voting and investment power over these securities. The reporting person and its director each disclaim beneficial ownership of these securities except to the extent of their respective pecuniary interests therein, and this report shall not be deemed an admission that the reporting person or its director is the beneficial owner of such securities for Section 16 or any other purpose. Robert A. Rucker is a director and executive officer of the issuer. /s/ Paul D. Broude, by power of attorney 2012-12-18