FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 12/16/2021 |
3. Issuer Name and Ticker or Trading Symbol
Kayne DL 2021, Inc. [ NONE ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 115.83 | D(1) | |
Common Stock | 180.576 | D(2) | |
Common Stock | 297.594 | D(3) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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Explanation of Responses: |
1. These Shares are owned directly by the UAW Chrysler Retirees Medical Benefits Plan. The UAW Chrysler Retirees Medical Benefits Plan is an employee welfare benefit plan established under the UAW RMBT. Hershel Harper is the Chief Investment Officer of the UAW RMBT. The UAW RMBT is deemed to be the indirect beneficial owner of these Shares by reason of its ability to direct the vote and/or disposition of such Shares. The UAW RMBT does not have a pecuniary interest in such Shares (within the meaning of Rule 16a-1(a)(2) under the Securities Exchange Act of 1934, as amended (the "Exchange Act")). Hershel Harper is deemed to be the indirect beneficial owner of these Shares by reason of his ability to direct the vote and/or disposition of such Shares. Hershel Harper does not have a pecuniary interest in such Shares (within the meaning of Rule 16a-1(a)(2) under the Exchange Act). |
2. These Shares are owned directly by the UAW Ford Retirees Medical Benefits Plan. The UAW Ford Retirees Medical Benefits Plan is an employee welfare benefit plan established under the UAW RMBT. Hershel Harper is the Chief Investment Officer of the UAW RMBT. The UAW RMBT is deemed to be the indirect beneficial owner of these Shares by reason of its ability to direct the vote and/or disposition of such Shares. The UAW RMBT does not have a pecuniary interest in such Shares (within the meaning of Rule 16a-1(a)(2) under the Exchange Act). Hershel Harper is deemed to be the indirect beneficial owner of these Shares by reason of his ability to direct the vote and/or disposition of such Shares. Hershel Harper does not have a pecuniary interest in such Shares (within the meaning of Rule 16a-1(a)(2) under the Exchange Act). |
3. These Shares are owned directly by the UAW GM Retirees Medical Benefits Plan. The UAW GM Retirees Medical Benefits Plan is an employee welfare benefit plan established under the UAW RMBT. Hershel Harper is the Chief Investment Officer of the UAW RMBT. The UAW RMBT is deemed to be the indirect beneficial owner of these Shares by reason of its ability to direct the vote and/or disposition of such Shares. The UAW RMBT does not have a pecuniary interest in such Shares (within the meaning of Rule 16a-1(a)(2) under the Exchange Act). Hershel Harper is deemed to be the indirect beneficial owner of these Shares by reason of his ability to direct the vote and/or disposition of such Shares. Hershel Harper does not have a pecuniary interest in such Shares (within the meaning of Rule 16a-1(a)(2) under the Exchange Act). |
Remarks: |
This Form 3 is being filed by (i) UAW Retiree Medical Benefits Trust, organized as a 501(c)(9) Voluntary Employee Beneficiary Association (the "UAW RMBT"); (ii) UAW Chrysler Retirees Medical Benefits Plan, as established and maintained by the UAW Chrysler Retirees Employees' Beneficiary Association, an employee organization within the meaning of Section 3(4) of the Employee Retirement Income Security Act of 1974, as amended ("ERISA") under the UAW RMBT (the "UAW Chrysler Retirees Medical Benefits Plan"); (iii) UAW Ford Retirees Medical Benefits Plan, as established and maintained by the UAW Ford Retirees Employees' Beneficiary Association, an employee organization within the meaning of Section 3(4) of ERISA under the UAW RMBT (the "UAW Ford Retirees Medical Benefits Plan"); (iv) UAW GM Retirees Medical Benefits Plan, as established and maintained by the UAW GM Retirees Employees' Beneficiary Association, an employee organization within the meaning of Section 3(4) of ERISA under the UAW RMBT (the "UAW GM Retirees Medical Benefits Plan"); and (v) Hershel Harper, a United States citizen and the Chief Investment Officer of the Trust (collectively, the "Reporting Persons"). The Reporting Persons are members of a group that owns more than 10% of the common stock (the "Shares") of Kayne DL 2021, Inc. (the "Issuer"). |
UAW RETIREE MEDICAL BENEFITS TRUST By: /s/ Garon Meikle Name: Garon Meikle Title: Controller | 12/16/2021 | |
UAW CHRYSLER RETIREES MEDICAL BENEFITS PLAN By: /s/ Garon Meikle Name: Garon Meikle Title: Controller | 12/16/2021 | |
UAW FORD RETIREES MEDICAL BENEFITS PLAN By: /s/ Garon Meikle Name: Garon Meikle Title: Controller | 12/16/2021 | |
UAW GM RETIREES MEDICAL BENEFITS PLAN By: /s/ Garon Meikle Name: Garon Meikle Title: Controller | 12/16/2021 | |
HERSHEL HARPER /s/ Hershel Harper | 12/16/2021 | |
** 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 5 (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 Number. |