0001209191-11-059693.txt : 20111206 0001209191-11-059693.hdr.sgml : 20111206 20111206154029 ACCESSION NUMBER: 0001209191-11-059693 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20111130 FILED AS OF DATE: 20111206 DATE AS OF CHANGE: 20111206 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Hennigar David CENTRAL INDEX KEY: 0001379268 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-13498 FILM NUMBER: 111245811 MAIL ADDRESS: STREET 1: 111 W MICHIGAN ST CITY: MILWAUKEE STATE: WI ZIP: 53203 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: ASSISTED LIVING CONCEPTS INC CENTRAL INDEX KEY: 0000929994 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-NURSING & PERSONAL CARE FACILITIES [8050] IRS NUMBER: 931148702 STATE OF INCORPORATION: NV FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: W140 N8981 LILLY ROAD CITY: MENOMONEE FALLS STATE: WI ZIP: 53051 BUSINESS PHONE: 262-257-8888 MAIL ADDRESS: STREET 1: W140 N8981 LILLY ROAD CITY: MENOMONEE FALLS STATE: WI ZIP: 53051 4 1 doc4.xml FORM 4 SUBMISSION X0304 4 2011-11-30 0 0000929994 ASSISTED LIVING CONCEPTS INC ALC 0001379268 Hennigar David 51 FOREST LANE BEDFORD A5 B4A 1H8 NOVA SCOTIA, CANADA 1 0 0 0 Class A Common Stock 2011-11-30 4 C 0 602 0.00 A 602 D Class B Common Stock 2011-11-30 4 C 0 560 0.00 D Class A Common Stok 602 5600 D Each share of Class B Common Stock is convertible at any time at the holder's election, into 1.075 shares of Class A Common Stock and has no expiration date. In addition, any shares off Class B Common Stock transferred to a person other than a permitted holder of Class B Common Stock, as provided in the Issuer's Amended and Restated Articles of Incorporation, will automatically convert into shares of Class A Common Stock on the same basis upon any such transfer. /s/ David Hennigar 2011-12-06