0000914190-16-000556.txt : 20160310 0000914190-16-000556.hdr.sgml : 20160310 20160310163902 ACCESSION NUMBER: 0000914190-16-000556 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20160308 FILED AS OF DATE: 20160310 DATE AS OF CHANGE: 20160310 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: KAMIN PETER H CENTRAL INDEX KEY: 0000937541 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35629 FILM NUMBER: 161498274 MAIL ADDRESS: STREET 1: ONE AVERY STREET STREET 2: 17 B CITY: BOSTON STATE: MA ZIP: 02111 4 1 edgar.xml PRIMARY DOCUMENT X0306 4 2016-03-08 0001552800 TILE SHOP HOLDINGS, INC. TTS 0000937541 KAMIN PETER H C/O TILE SHOP HOLDINGS, INC. 14000 CARLSON PARKWAY PLYMOUTH MN 55441 1 0 0 0 Common Stock 388799 D Common Stock 2016-03-08 4 P 0 7453 12.62 A 7453 I By Peter H. Kamin Family Foundation Common Stock 379059 I By Peter H. Kamin Revocable Trust Common Stock 228216 I By Peter H. Kamin Childrens Trust Common Stock 160723 I By 3K Limited Partnership Common Stock 135361 I By Peter H. Kamin GST Trust Common Stock 100 I By Son Includes 3,602 shares of restricted stock granted pursuant to the Company's 2012 Omnibus Award Plan, which are subject to a purchase option in favor of the Company until August 21, 2016. These securities are owned by the Peter H. Kamin Family Foundation. The reporting person is trustee of the foundation. 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 Peter H. Kamin Revocable Trust dated February 2003. The reporting person is trustee of the trust. 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 Peter H. Kamin Childrens Trust dated March 1997. The reporting person is trustee of the trust. 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 3K Limited Partnership. The reporting person is general partner of the limited partnership. 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 Peter H. Kamin GST Trust. The reporting person is trustee of the trust. 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 reporting person's son. 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. /s/ Elizabeth M. Dunshee as Attorney-in-Fact for Peter H. Kamin pursuant to Power of Attorney previously filed. 2016-03-10