0001104659-23-071696.txt : 20230615 0001104659-23-071696.hdr.sgml : 20230615 20230615174639 ACCESSION NUMBER: 0001104659-23-071696 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20230613 FILED AS OF DATE: 20230615 DATE AS OF CHANGE: 20230615 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Kamin Peter 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: 231018699 MAIL ADDRESS: STREET 1: 2720 DONALD ROSS ROAD STREET 2: #311 CITY: PALM BEACH GARDENS STATE: FL ZIP: 33410 FORMER NAME: FORMER CONFORMED NAME: KAMIN PETER H DATE OF NAME CHANGE: 19950210 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: 763-852-2950 MAIL ADDRESS: STREET 1: 14000 CARLSON PARKWAY CITY: PLYMOUTH STATE: MN ZIP: 55441 4 1 tm2318831-4_4seq1.xml OWNERSHIP DOCUMENT X0407 4 2023-06-13 0 0001552800 TILE SHOP HOLDINGS, INC. TTSH 0000937541 Kamin Peter C/O TILE SHOP HOLDINGS, INC 14000 CARLSON PARKWAY PLYMOUTH MN 55441 1 0 1 0 0 Common Stock 2023-06-13 4 A 0 38248 4.9677 A 3447632 D Common Stock 1695320 I By Peter H. Kamin Revocable Trust Common Stock 1033733 I By Peter H. Kamin Childrens Trust Common Stock 333495 I By 3K Limited Partnership Common Stock 117453 I By Peter H. Kamin Family Foundation Common Stock 328711 I By Peter H. Kamin GST Trust Represents shares of restricted stock granted pursuant to the Company's 2021 Omnibus Equity Compensation Plan, which are subject to a risk of forfeiture until the earlier of (a) the date of the Company's next annual meeting of stockholders and (b) June 13, 2024. 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 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 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. /s/ Mark Davis as Attorney-in-Fact for Peter H. Kamin pursuant to Power of Attorney 2023-06-15