Annual Statement of Changes in Beneficial Ownership (5)
14 February 2023 - 7:45AM
Edgar (US Regulatory)
FORM 5
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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).
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Form 3 Holdings Reported
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Form 4 Transactions Reported |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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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
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HOWELL HILTON H JR | 2. Issuer Name and Ticker or Trading SymbolATLANTIC AMERICAN CORP [AAME] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__X__ Director _____ 10% Owner
__X__ Officer (give title below) _____ Other (specify below)
Chairman, President & CEO |
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(Last)
(First)
(Middle)
4370 PEACHTREE ROAD, N.E. | 3. Statement for Issuer's Fiscal Year Ended (MM/DD/YYYY)
12/31/2022 |
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(Street)
ATLANTA, GA 30319
(City)
(State)
(Zip)
| 4. If Amendment, Date Original Filed(MM/DD/YYYY)
| 6. Individual or Joint/Group Filing(Check Applicable Line)
_X_ Form Filed by One Reporting Person
___ Form Filed by More than One Reporting Person
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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. Trans. Date | 2A. Deemed Execution Date, if any | 3. Trans. Code
(Instr. 8) | 4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(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 | | | | | | | 517272 | D | |
| Common Stock | | | | | | | 309046 (1) | I | By 401(k) Plan |
| Common Stock | 5/1/2022 | | J (2) | 30368 | D(2) | $0.00 | 34075 (3) | I | By Spouse |
| Common Stock | | | | | | | 408765 (4) | I | Trust F/B/O Children |
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 Derivate Security
(Instr. 3) | 2. Conversion or Exercise Price of Derivative Security | 3. Trans. Date | 3A. Deemed Execution Date, if any | 4. Trans. 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
(MM/DD/YYYY) | 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 at End of Issuer's Fiscal Year
(Instr. 4) | 10. Ownership Form of Derivative Security: 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) | Reflects the reporting person's interest in equivalent shares held by the unitized stock fund in the Atlantic American Corporation 401(k) Plan. |
| (2) | Represents a disposition of 30,368 shares formerly held by Mr. Howell's spouse, Robin R. Howell, as custodian for the benefit of their children. On the transaction date, the shares were transferred to the individual holdings of the adult children. |
| (3) | Mr. Howell has an indirect interest in the following shares owned directly or indirectly by his spouse, Robin R. Howell: 31,900 shares owned directly and 2,175 shares owned in an IRA account. Mr. Howell disclaims beneficial ownership of all such shares. |
| (4) | Shares held in a trust for the benefit of Mr. Howell's children and over which Mr. Howell's mother-in-law serves as trustee. Mr. Howell disclaims beneficial ownership of all such shares. |
Reporting Owners
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| Reporting Owner Name / Address | Relationships |
| Director | 10% Owner | Officer | Other |
HOWELL HILTON H JR
4370 PEACHTREE ROAD, N.E.
ATLANTA, GA 30319 | X |
| Chairman, President & CEO |
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Signatures
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| /s/ Hilton H. Howell, Jr. | | 2/13/2023 |
| **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 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 control number. |
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