0001179022-12-000079.txt : 20121203 0001179022-12-000079.hdr.sgml : 20121203 20121203151745 ACCESSION NUMBER: 0001179022-12-000079 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20121201 FILED AS OF DATE: 20121203 DATE AS OF CHANGE: 20121203 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Forman Robert S Jr CENTRAL INDEX KEY: 0001470912 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-15669 FILM NUMBER: 121237350 MAIL ADDRESS: STREET 1: 3350 RIVERWOOD PARKWAY SUITE 1400 CITY: ATLANTA STATE: GA ZIP: 30339 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: GENTIVA HEALTH SERVICES INC CENTRAL INDEX KEY: 0001096142 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-HOME HEALTH CARE SERVICES [8082] IRS NUMBER: 364335801 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 3350 RIVERWOOD PARKWAY STREET 2: SUITE 1400 CITY: ATLANTA STATE: GA ZIP: 30339 BUSINESS PHONE: 7709516450 MAIL ADDRESS: STREET 1: 3350 RIVERWOOD PARKWAY STREET 2: SUITE 1400 CITY: ATLANTA STATE: GA ZIP: 30339 FORMER COMPANY: FORMER CONFORMED NAME: OLSTEN HEALTH SERVICES HOLDING CORP DATE OF NAME CHANGE: 19991001 4 1 edgar.xml PRIMARY DOCUMENT X0306 4 2012-12-01 0001096142 GENTIVA HEALTH SERVICES INC GTIV 0001470912 Forman Robert S Jr 3350 RIVERWOOD PKWY, SUITE 1400 ATLANTA GA 30339 1 0 0 0 Common stock units 0 2012-12-01 4 A 0 3014 0 A Common stock 3014 26629 D The common stock units of Gentiva Health Services, Inc. are convertible to shares of common stock of Gentiva at a conversion ratio of one unit for one share of common stock. The common stock units are convertible upon the date of termination of service to the Issuer. David Brown, by power of attorney 2012-12-03