0000076605-21-000200.txt : 20211206 0000076605-21-000200.hdr.sgml : 20211206 20211206204930 ACCESSION NUMBER: 0000076605-21-000200 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20211202 FILED AS OF DATE: 20211206 DATE AS OF CHANGE: 20211206 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Petkovich Jacob R CENTRAL INDEX KEY: 0001834052 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-03922 FILM NUMBER: 211474487 MAIL ADDRESS: STREET 1: 107 W. FRANKLIN STREET STREET 2: PO BOX 638 CITY: ELKHART STATE: IN ZIP: 46515 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: PATRICK INDUSTRIES INC CENTRAL INDEX KEY: 0000076605 STANDARD INDUSTRIAL CLASSIFICATION: MOTOR VEHICLE PARTS & ACCESSORIES [3714] IRS NUMBER: 351057796 STATE OF INCORPORATION: IN FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 107 WEST FRANKLIN STREET PO BOX 638 CITY: ELKHART STATE: IN ZIP: 46515 BUSINESS PHONE: 574-294-7511 MAIL ADDRESS: STREET 1: 107 WEST FRANKLIN STREET PO BOX 638 CITY: ELKHART STATE: IN ZIP: 46515 4 1 wf-form4_163884175658096.xml FORM 4 X0306 4 2021-12-02 0 0000076605 PATRICK INDUSTRIES INC PATK 0001834052 Petkovich Jacob R 107 W. FRANKLIN STREET ELKHART IN 46515 0 1 0 0 EVP Finance, CFO & Treasurer Common Stock 2021-12-02 4 M 0 10500 66.66 A 51121 D Common Stock 2021-12-02 4 F 0 8871 84.83 D 42250 D Common Stock Options 66.66 2021-12-02 4 M 0 10500 0 D 2021-05-14 2029-05-14 Common Stock 10500.0 19500 D Reflects the date the stock options became fully exercisable. /s/ Jacob R. Petkovich by Andy L. Nemeth, attorney-in-fact 2021-12-06