0001104659-22-109628.txt : 20221018 0001104659-22-109628.hdr.sgml : 20221018 20221018132343 ACCESSION NUMBER: 0001104659-22-109628 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20221014 FILED AS OF DATE: 20221018 DATE AS OF CHANGE: 20221018 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: UAW GM RETIREES MEDICAL BENEFITS PLAN CENTRAL INDEX KEY: 0001795050 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 814-01393 FILM NUMBER: 221315554 BUSINESS ADDRESS: STREET 1: 200 WALKER STREET CITY: DETROIT STATE: MI ZIP: 48207 BUSINESS PHONE: 313-324-5928 MAIL ADDRESS: STREET 1: 200 WALKER STREET CITY: DETROIT STATE: MI ZIP: 48207 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: UAW Ford Retireees Medical Benefits Plan CENTRAL INDEX KEY: 0001795052 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 814-01393 FILM NUMBER: 221315555 BUSINESS ADDRESS: STREET 1: 200 WALKER STREET CITY: DETROIT STATE: MI ZIP: 48207 BUSINESS PHONE: 313-324-5928 MAIL ADDRESS: STREET 1: 200 WALKER STREET CITY: DETROIT STATE: MI ZIP: 48207 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: UAW Chrysler Retireees Medical Benefits Plan CENTRAL INDEX KEY: 0001795057 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 814-01393 FILM NUMBER: 221315556 BUSINESS ADDRESS: STREET 1: 200 WALKER STREET CITY: DETROIT STATE: MI ZIP: 48207 BUSINESS PHONE: 313-324-5928 MAIL ADDRESS: STREET 1: 200 WALKER STREET CITY: DETROIT STATE: MI ZIP: 48207 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Kayne DL 2021, Inc. CENTRAL INDEX KEY: 0001850787 IRS NUMBER: 862440860 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 811 MAIN STREET, 14TH FLOOR CITY: HOUSTON STATE: TX ZIP: 77002 BUSINESS PHONE: 713-493-2020 MAIL ADDRESS: STREET 1: 811 MAIN STREET, 14TH FLOOR CITY: HOUSTON STATE: TX ZIP: 77002 4 1 tm2228405-2_4seq1.xml OWNERSHIP DOCUMENT X0306 4 2022-10-14 0 0001850787 Kayne DL 2021, Inc. NONE 0001795057 UAW Chrysler Retireees Medical Benefits Plan C/O UAW RETIREE MEDICAL BENEFITS TRUST, 1155 BREWERY PARK BLVD., SUITE 400 DETROIT MI 48207 0 0 1 0 0001795052 UAW Ford Retireees Medical Benefits Plan C/O UAW RETIREE MEDICAL BENEFITS TRUST, 1155 BREWERY PARK BLVD., SUITE 400 DETROIT MI 48207 0 0 1 0 0001795050 UAW GM RETIREES MEDICAL BENEFITS PLAN C/O UAW RETIREE MEDICAL BENEFITS TRUST, 1155 BREWERY PARK BLVD., SUITE 400 DETROIT MI 48207 0 0 1 0 Common Stock 2022-10-14 4 P 0 952.299 5068.00 A 3011.825 D Common Stock 2022-10-14 4 P 0 1484.609 5068.00 A 4695.357 D Common Stock 2022-10-14 4 P 0 2446.675 5068.00 A 7738.072 D These shares of common stock (the "Shares") of Kayne DL 2021, Inc. (the "Issuer") are owned directly by the UAW Chrysler Retirees Medical Benefits Plan, as established and maintained by the UAW Chrysler Retirees Employees' Beneficiary Association, an employee organization within the meaning of Section 3(4) of the Employee Retirement Income Security Act of 1974, as amended ("ERISA") under the UAW Retiree Medical Benefits Trust, organized as a 501(c)(9) Voluntary Employee Beneficiary Association (the "UAW RMBT"). These Shares of the Issuer are owned directly by the UAW Ford Retirees Medical Benefits Plan, as established and maintained by the UAW Ford Retirees Employees' Beneficiary Association, an employee organization within the meaning of Section 3(4) of ERISA under the UAW RMBT. These Shares of the Issuer are owned directly by the UAW GM Retirees Medical Benefits Plan, as established and maintained by the UAW GM Retirees Employees' Beneficiary Association, an employee organization within the meaning of Section 3(4) of ERISA under the UAW RMBT. UAW CHRYSLER RETIREES MEDICAL BENEFITS PLAN By: /s/ Garon Meikle Name: Garon Meikle Title: Chief Financial Officer 2022-10-18 UAW FORD RETIREES MEDICAL BENEFITS PLAN By: /s/ Garon Meikle Name: Garon Meikle Title: Chief Financial Officer 2022-10-18 UAW GM RETIREES MEDICAL BENEFITS PLAN By: /s/ Garon Meikle Name: Garon Meikle Title: Chief Financial Officer 2022-10-18