SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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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1. Name and Address of Reporting Person*
JACKSON SAM
(Last) (First) (Middle)
30 FRANK LLOYD WRIGHT DR
(Street)
ANN ARBOR MI 48105
(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
11/06/2023 		3. Issuer Name and Ticker or Trading Symbol
DOMINOS PIZZA INC [ DPZ ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
EVP, Human Resources
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock, $0.01 par value 2,500(1)(2)(3)(4)(5)(6)(7) D
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Option to Purchase Common Stock 07/18/2022 07/18/2028 Common Stock, $0.01 par value 520 $283.68 D
Option to Purchase Common Stock 07/10/2023 07/10/2029 Common Stock, $0.01 par value 590 $275.35 D
Option to Purchase Common Stock 07/15/2024(8) 07/15/2030 Common Stock, $0.01 par value 380 $413.68 D
Option to Purchase Common Stock 07/15/2024(8) 07/15/2030 Common Stock, $0.01 par value 120 $413.68 D
Option to Purchase Common Stock 03/31/2024(9) 03/31/2031 Common Stock, $0.01 par value 450 $367.79 D
Option to Purchase Common Stock 03/10/2025(10) 03/10/2032 Common Stock, $0.01 par value 429 $393.14 D
Option to Purchase Common Stock 03/10/2026(11) 03/10/2033 Common Stock, $0.01 par value 530 $300.16 D
Explanation of Responses:
1. Includes 75 shares of common stock representing the final tranche of an original grant of performance-based restricted stock that shall vest on July 15, 2024 if applicable performance conditions are achieved.
2. Includes 25 shares of common stock representing the final tranche of an original grant of performance-based restricted stock that shall vest on July 15, 2024 if applicable performance conditions are achieved.
3. Includes 115 shares of common stock representing the final tranche of an original restricted stock unit award with service-based vesting criteria that shall vest on March 31, 2024. Shares are issued and delivered following each vesting tranche of the award.
4. Includes 147 shares of common stock representing the final tranche of an original restricted stock unit award with service-based vesting criteria that shall vest on July 19, 2024. Shares are issued and delivered following each vesting tranche of the award.
5. Includes 1,578 shares of common stock representing an original restricted stock unit award with service-based vesting criteria that shall vest one-fourth on March 10, 2024, one-fourth on March 10, 2025 and one-half on March 10, 2026. Shares are issued and delivered following each vesting tranche of the award.
6. Includes 237 shares of common stock representing the final two tranches of an original restricted stock unit award with service-based vesting criteria that shall vest one-half on each of March 10, 2024 and March 10, 2025. Shares are issued and delivered following each vesting tranche of the award.
7. Includes 323 shares of common stock representing an original restricted stock unit award with service-based vesting criteria that shall vest one-third on each of March 10, 2024, March 10, 2025 and March 10, 2026. Shares are issued and delivered following each vesting tranche of the award.
8. The options to purchase common stock vest one-fourth each year on the anniversary date of the grant date. Thus, one-fourth vested on each of July 15, 2021, July 15, 2022 and July 15, 2023 and one-fourth shall vest on July 15, 2024.
9. The options to purchase common stock vest one-third each year on the anniversary date of the grant date. Thus, one-third vested on each of March 31, 2022 and March 31, 2023 and one-third shall vest on March 31, 2024.
10. The options to purchase common stock vest one-third each year on the anniversary date of the grant date. Thus, one-third vested on March 10, 2023 and one-third shall vest on each of March 10, 2024 and March 10, 2025.
11. The options to purchase common stock vest one-third each year on the anniversary date of the grant date. Thus, one-third shall vest on each of March 10, 2024, March 10, 2025 and March 10, 2026.
Remarks:
/s/ Kevin S. Morris, attorney-in-fact 11/08/2023
** 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 5 (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.
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