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