0001171843-21-006492.txt : 20210915 0001171843-21-006492.hdr.sgml : 20210915 20210915095948 ACCESSION NUMBER: 0001171843-21-006492 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210915 FILED AS OF DATE: 20210915 DATE AS OF CHANGE: 20210915 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HOLT DONALD CENTRAL INDEX KEY: 0001225044 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-13677 FILM NUMBER: 211254505 MAIL ADDRESS: STREET 1: 21 FIELD STONE DR CITY: MECHANICSBURG STATE: PA ZIP: 17055 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: MID PENN BANCORP INC CENTRAL INDEX KEY: 0000879635 STANDARD INDUSTRIAL CLASSIFICATION: STATE COMMERCIAL BANKS [6022] IRS NUMBER: 251666413 STATE OF INCORPORATION: PA FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 349 UNION STREET CITY: MILLERSBURG STATE: PA ZIP: 17061 BUSINESS PHONE: 8666427736 MAIL ADDRESS: STREET 1: 349 UNION STREET CITY: MILLERSBURG STATE: PA ZIP: 17061 4 1 ownership.xml X0306 4 2021-09-15 0 0000879635 MID PENN BANCORP INC MPB 0001225044 HOLT DONALD ONE WINCHESTER COURT MECHANICSBURG PA 17050 0 1 0 0 Interim CFO Mid Penn Bancorp, Inc. Common Stock 2021-09-15 4 A 0 500 0 A 500 D Shares granted in the form of restricted stock, all of which shall vest upon completion of Mr. Holt's appointment as Interim Chief Financial Officer. /s/ Donald F. Holt 2021-09-15