0001437749-12-011507.txt : 20121113 0001437749-12-011507.hdr.sgml : 20121112 20121113114635 ACCESSION NUMBER: 0001437749-12-011507 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20120706 FILED AS OF DATE: 20121113 DATE AS OF CHANGE: 20121113 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Ansley T. Michael CENTRAL INDEX KEY: 0001434679 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-53577 FILM NUMBER: 121197090 MAIL ADDRESS: STREET 1: 21751 W. ELEVEN MILE ROAD STREET 2: SUITE 208 CITY: SOUTHFIELD STATE: MI ZIP: 48076 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Diversified Restaurant Holdings, Inc. CENTRAL INDEX KEY: 0001394156 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MANAGEMENT SERVICES [8741] IRS NUMBER: 030606420 STATE OF INCORPORATION: NV FISCAL YEAR END: 1227 BUSINESS ADDRESS: STREET 1: 27680 FRANKLIN ROAD CITY: SOUTHFIELD STATE: MI ZIP: 48034 BUSINESS PHONE: (248) 223-9160 MAIL ADDRESS: STREET 1: 27680 FRANKLIN ROAD CITY: SOUTHFIELD STATE: MI ZIP: 48034 FORMER COMPANY: FORMER CONFORMED NAME: Diversified Restaurants Holding, Inc. DATE OF NAME CHANGE: 20070322 4 1 rdgdoc.xml FORM 4(V) GIFTED SHARES X0306 4 2012-07-06 0001394156 Diversified Restaurant Holdings, Inc. DFRH 0001434679 Ansley T. Michael 27680 FRANKLIN ROAD SOUTHFIELD MI 48034 1 1 1 President and CEO Common Stock 2012-07-06 5 G 0 20900 0 D 11122600 D Common Stock 2012-07-06 5 G 0 9000 0 D 11113600 D Common Stock 2012-07-06 5 G 0 9000 0 A 9000 I By reporting person as UGMA custodian for children Option to purchase common stock -- Right to Buy 2.50 2011-07-31 2016-07-31 Common Stock 10000 10000 D Option to purchase common stock -- Right to Buy 2.50 2012-07-31 2016-07-31 Common Stock 10000 10000 D Option to purchase common stock -- Right to Buy 2.50 2013-07-31 2016-07-31 Common Stock 10000 10000 D Transfer of 9,000 shares of common stock to the reporting person as custodian for his three children under Uniform Gifts to Minors Act. The reporting person disclaims beneficial ownership of these shares, and this report shall not be deemed an admission that the reporting person is the beneficial owner of these shares for purposes of Section 16 or for any other purpose. /s/ T. Michael Ansley 2012-11-13