0000914190-19-000235.txt : 20190718 0000914190-19-000235.hdr.sgml : 20190718 20190718163408 ACCESSION NUMBER: 0000914190-19-000235 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20190716 FILED AS OF DATE: 20190718 DATE AS OF CHANGE: 20190718 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: RUCKER ROBERT A CENTRAL INDEX KEY: 0001555206 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35629 FILM NUMBER: 19961655 MAIL ADDRESS: STREET 1: 14000 CARLSON PARKWAY CITY: PLYMOUTH STATE: MN ZIP: 55441 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 edgar.xml PRIMARY DOCUMENT X0306 4 2019-07-16 0001552800 TILE SHOP HOLDINGS, INC. TTS 0001555206 RUCKER ROBERT A C/O TILE SHOP HOLDINGS, INC. 14000 CARLSON PARKWAY PLYMOUTH MN 55441 1 0 1 0 Common Stock 2019-07-16 4 A 0 24571 0 A 256396 D Common Stock 3662428 I By The Tile Shop, Inc. Common Stock 775000 I By 2017 Grantor Retained Annuity Trust Common Stock 515000 I By 2017 Grantor Retained Annuity Trust II Common Stock 500000 I By 2018 Grantor Retained Annuity Trust Common Stock 3380 I By Spouse Common Stock 3380 I By UGMA #1 Common Stock 3380 I By UGMA #2 Common Stock 3380 I By UGMA #3 Common Stock 3380 I By UGMA #4 Common Stock 3380 I By UGMA #5 Common Stock 3380 I By UGMA #6 Common Stock 3380 I By UGMA #7 Represents 24,571 shares of restricted stock granted pursuant to the Company's 2012 Omnibus Award 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) July 16, 2020. These securities are owned by The Tile Shop, Inc. The reporting person is the sole director of The Tile Shop, Inc. 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/ Amanda Lorentz as Attorney-in-Fact for Robert Rucker pursuant to Power of Attorney previously filed. 2019-07-18