FORM 5 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). | |||||||||||||||||
Form 3 Holdings Reported. | |||||||||||||||||
Form 4 Transactions Reported. |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
Diplomat Pharmacy, Inc. [ DPLO ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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3. Statement for Issuer's Fiscal Year Ended
(Month/Day/Year) 12/31/2018 | ||||||||||||||||||||||||||
4. If Amendment, Date of Original Filed
(Month/Day/Year) |
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | |||||||||||||||
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1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned at end of Issuer's Fiscal Year (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||||||
Amount | (A) or (D) | Price | |||||||||||||
Common Stock | 5,222 | D | |||||||||||||
Common Stock | 05/30/2018 | G(1) | 50,000 | D | $0 | 1,280,099 | I | Philip R. Hagerman Revocable Trust(2) | |||||||
Common Stock | 3,391,609 | I | 2007 Hagerman Family GST(3) | ||||||||||||
Common Stock | 3,600,091 | I | The JH GST Trust(2) | ||||||||||||
Common Stock | 1,475,876 | I | 2013 Irrev. Exempt Trust for Daughter(3) | ||||||||||||
Common Stock | 1,475,876 | I | 2013 Irrev. Exempt Trust for Son(3) | ||||||||||||
Common Stock | 1,075,293 | I | 2013 Irrev. Exempt Trust for Daughter(2) | ||||||||||||
Common Stock | 1,311,292 | I | 2013 Irrev. Exempt Trust for Daughter(2) | ||||||||||||
Common Stock | 313,337 | I | 2014 Irrev. Exempt Trust for Son(3) | ||||||||||||
Common Stock | 313,337 | I | 2014 Irrev. Exempt Trust for Daughter(3) | ||||||||||||
Common Stock | 313,337 | I | 2014 Irrev. Exempt Trust for Daughter(2) | ||||||||||||
Common Stock | 313,337 | I | 2014 Irrev. Exempt Trust for Daughter(2) | ||||||||||||
Common Stock | 05/30/2018 | G(4) | 50,000 | D | $0 | 367,528 | I | Jocelyn Hagerman Living Trust(3) | |||||||
Common Stock | 263,500 | I | JH Marital Trust(2) | ||||||||||||
Common Stock | 272,000 | I | PH Marital Trust(3) | ||||||||||||
Common Stock | 394,910 | I | Irrevocable Trust for Son | ||||||||||||
Common Stock | 394,910 | I | Irrevocable Trust for Daughter | ||||||||||||
Common Stock | 367,256 | I | Irrevocable Non-Exempt Trust for Son | ||||||||||||
Common Stock | 367,256 | I | Irrevocable Non-Exempt Trust for Daughter |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | ||||||||||||||
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1. Title of Derivative Security (Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
1. On May 30, 2018, 50,000 shares held by the Philip R. Hagerman Revocable Trust were donated to The Hagerman Foundation, an unaffiliated, nonprofit corporation. |
2. These shares are indirectly owned by Mr. Hagerman as trustee of the Philip R. Hagerman Revocable Trust, The JH GST Trust, the 2013 Irrevocable Exempt Trusts and 2014 Irrevocable Exempt Trusts for two daughters, and the JH Marital Trust. |
3. Jocelyn Hagerman is Mr. Hagerman's wife. These shares are indirectly owned by her as a trustee of the 2007 Hagerman Family GST Trust, the 2013 Irrevocable Exempt Trusts and 2014 Irrevocable Exempt Trusts for a son and daughter, the Jocelyn Hagerman Living Trust, and the PH Marital Trust. |
4. On May 30, 2018, 50,000 shares held by the Jocelyn Hagerman Living Trust were donated to The Hagerman Foundation, an unaffiliated, nonprofit corporation. |
/s/ Christina Flint, by Power of Attorney | 02/14/2019 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v). | ||
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |