Initial Statement of Beneficial Ownership (3)
17 October 2014 - 7:31AM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
Estimated average burden
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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
*
WEINER RUSSELL J
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2. Date of Event Requiring Statement (MM/DD/YYYY)
10/14/2014
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3. Issuer Name
and
Ticker or Trading Symbol
DOMINOS PIZZA INC [DPZ]
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(Last)
(First)
(Middle)
DOMINO'S PIZZA, 30 FRANK LLOYD WRIGHT DRIVE
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
_____ 10% Owner
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X
___ Officer (give title below)
_____ Other (specify below)
President, Domino's U.S.A. /
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(Street)
ANN ARBOR, MI 48105
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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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 Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Common Stock, $0.01 par value
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363125.434
(1)
(2)
(3)
(4)
(5)
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D
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Common Stock, $0.01 par value
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744.800
(6)
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I
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401(k) Savings Plan
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Option to Purchase Common Stock
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6/1/2012
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9/22/2018
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Common Stock, $.001 par value
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45000
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$7.06
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D
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Option to Purchase Common Stock
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9/22/2012
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9/22/2018
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Common Stock, $0.01 par value
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180000
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$10.06
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D
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Option to Purchase Common Stock
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7/16/2012
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7/16/2019
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Common Stock, $0.01 par value
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30000
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$7.97
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D
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Option to Purchase Common Stock
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7/20/2013
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7/20/2020
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Common Stock, $0.01 par value
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8334
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$9.32
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D
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Option to Purchase Common Stock
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7/20/2012
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7/20/2020
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Common Stock, $0.01 par value
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16666
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$12.32
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D
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Option to Purchase Common Stock
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7/20/2014
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7/20/2021
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Common Stock, $0.01 par value
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10000
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$22.78
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D
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Option to Purchase Common Stock
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7/20/2012
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7/20/2021
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Common Stock, $0.01 par value
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5000
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$25.78
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D
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Option to Purchase Common Stock
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7/20/2015
(7)
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7/20/2022
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Common Stock, $0.01 par value
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9690
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$32.69
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D
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Option to Purchase Common Stock
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2/27/2017
(8)
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2/27/2023
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Common Stock, $0.01 par value
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37020
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$46.83
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D
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Option to Purchase Common Stock
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7/17/2017
(9)
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7/17/2023
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Common Stock, $0.01 par value
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17110
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$63.05
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D
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Option to Purchase Common Stock
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7/16/2018
(10)
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7/16/2024
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Common Stock, $0.01 par value
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15960
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$73.04
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D
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Explanation of Responses:
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(
1)
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Includes 3,827 shares of common stock representing one-third of an original grant of performance-based restricted stock that shall vest on July 20, 2015 if applicable performance conditions are achieved.
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(
2)
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Includes 3,870 shares of common stock representing three-fourths of an original grant of performance-based restricted stock that shall vest one-third on each of July 17, 2015, July 17, 2016 and July 17, 2017 if applicable performance conditions are achieved.
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(
3)
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Includes 8,768 shares of common stock representing three-fourths of an original grant of performance-based restricted stock that shall vest one-third on each of February 27, 2015, February 27, 2016 and February 27, 2017 if applicable performance conditions are achieved.
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(
4)
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Includes 4,590 shares of common stock representing a grant of performance-based restricted stock that shall vest one-fourth on each of July 16, 2015, July 16, 2016, July 16, 2017 and July 16, 2018 if applicable performance conditions are achieved.
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(
5)
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Includes 362.634 shares held in Domino's Employee Stock Payroll Deduction Plan.
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(
6)
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Total shares held in the Domino's Pizza 401(k) Savings Plan.
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(
7)
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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 July 20, 2013 and July 20, 2014, and one-third shall vest on July 20, 2015.
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(
8)
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The options to purchase common stock vest one-fourth each year on the anniversary date of the grant date. Thus, one-fourth vested on February 27, 2014, and one-fourth shall vest on each of February 27, 2015, February 27, 2016 and February 27, 2017.
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(
9)
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The options to purchase common stock vest one-fourth each year on the anniversary date of the grant date. Thus, one-fourth vested on July 17, 2014, and one-fourth shall vest on each of July 17, 2015, July 17, 2016 and July 17, 2017.
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(
10)
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The options to purchase common stock vest one-fourth each year on the anniversary date of the grant date. Thus, one-fourth shall vest on each of July 16, 2015, July 16, 2016, July 16, 2017 and July 16, 2018.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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WEINER RUSSELL J
DOMINO'S PIZZA
30 FRANK LLOYD WRIGHT DRIVE
ANN ARBOR, MI 48105
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President, Domino's U.S.A.
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Signatures
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/s/ Adam J. Gacek, attorney-in-fact
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10/16/2014
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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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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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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