0001179110-17-012319.txt : 20170914 0001179110-17-012319.hdr.sgml : 20170914 20170914213338 ACCESSION NUMBER: 0001179110-17-012319 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20170906 FILED AS OF DATE: 20170914 DATE AS OF CHANGE: 20170914 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Barrett Peter D CENTRAL INDEX KEY: 0001608380 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-08183 FILM NUMBER: 171086733 MAIL ADDRESS: STREET 1: 1229 RIDGEDALE CITY: SOUTH BEND STATE: IN ZIP: 46614 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: SUPREME INDUSTRIES INC CENTRAL INDEX KEY: 0000350846 STANDARD INDUSTRIAL CLASSIFICATION: TRUCK & BUS BODIES [3713] IRS NUMBER: 751670945 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 2581 EAST KERCHER ROAD CITY: GOSHEN STATE: IN ZIP: 46528 BUSINESS PHONE: 5746423070 MAIL ADDRESS: STREET 1: 2581 EAST KERCHER ROAD CITY: GOSHEN STATE: IN ZIP: 46528 FORMER COMPANY: FORMER CONFORMED NAME: EXPLORATION SURVEYS INC DATE OF NAME CHANGE: 19850813 4 1 edgar.xml FORM 4 - X0306 4 2017-09-06 0 0000350846 SUPREME INDUSTRIES INC STS 0001608380 Barrett Peter D 2581 EAST KERCHER ROAD GOSHEN IN 46528 1 0 0 0 Class A Common Stock 2017-09-06 4 J 0 26700 0 A 26700 I By Trust Class A Common Stock 2017-09-06 4 J 0 26700 0 D 0 I By Trust Class A Common Stock 33321 D Class B Common Stock 29467 D Represents shares of Class A common stock of Supreme Industries, Inc., par value $0.10 per share ("Class A Shares"), that were ultimately received in connection with a distribution by an independently controlled limited liability company to its members. Represents Class A Shares held directly by the Peter D. Barrett 2012 Irrevocable Trust (the "Trust"). Peter D. Barrett is the trustee and beneficiary of, and may be deemed to beneficially own securities held by, the Trust. This statement is filed by and on behalf of Peter D. Barrett. Mr. Barrett and the Trust are the direct beneficial owners of the securities covered by this statement. The reporting person states that neither the filing of this statement nor anything herein shall be deemed an admission that such person is, for purposes of Section 16 of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), or otherwise, the beneficial owner of any securities covered by this statement. The reporting person disclaims beneficial ownership of the securities covered by this statement, except to the extent of the pecuniary interest of such person in such securities. Represents Class A Shares that were distributed by the Trust to Mr. Barrett, as the sole beneficiary of the Trust (the "Trust Distribution"). Includes all 26,700 Class A Shares that were distributed by the Trust to Mr. Barrett in connection with the Trust Distribution. The acquisition of such Class A Shares by Mr. Barrett in connection with the Trust Distribution constituted a change in the form of beneficial ownership without a change in pecuniary interest that is exempt from Section 16 of the Exchange Act pursuant to Rule 16a-13 thereunder. Rule 16a-9(a) under the Exchange Act may also exempt the acquisition of such Class A Shares by Mr. Barrett in connection with the Trust Distribution from Section 16 of the Exchange Act. Represents shares of Class B common stock of Supreme Industries, Inc., par value $0.10 per share ("Class B Shares"). Class B Shares are freely convertible on a one-to-one basis into an equal number of Class A Shares. s/ Julia A. Gardner, Attorney-in-Fact for Peter D. Barrett 2017-09-14