SEC FORM
3
SEC Form 3
FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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OMB APPROVAL |
OMB Number: |
3235-0104 |
Estimated average burden |
hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
C/O TILE SHOP HOLDINGS, INC. |
14000 CARLSON PARKWAY |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 09/06/2019
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3. Issuer Name and Ticker or Trading Symbol
TILE SHOP HOLDINGS, INC.
[ TTS ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
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10% Owner |
X |
Officer (give title below) |
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Other (specify below) |
Chief Financial Officer |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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Table I - Non-Derivative Securities Beneficially Owned |
1. Title of Security (Instr.
4)
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2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Explanation of Responses: |
Remarks: |
No securities are beneficially owned. |
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/s/ Amanda Lorentz as Attorney-in-Fact for Nancy DiMattia pursuant to Power of Attorney filed herewith. |
09/13/2019 |
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** Signature of Reporting Person |
Date |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
* If the form is filed by more than one reporting person,
see
Instruction
5
(b)(v). |
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |
POWER OF ATTORNEY
The undersigned hereby constitutes and appoints Mark Davis, John R. Houston,
Amanda Lorentz and Andrew Nick, or either of them acting alone, the
undersigned's true and lawful attorneys-in-fact and agent with full power
of substitution and resubstitution, for the undersigned and in the
undersigned's name, place and stead, in any and all capacities, to sign any
or all Forms 3, 4 and 5 relating to beneficial ownership of securities of The
Tile Shop Holdings, Inc. (the "Issuer"), to file the same, with all exhibits
thereto and other documents in connection therewith, with the Securities and
Exchange Commission and to deliver a copy of the same to the Issuer, granting
unto said attorney-in-fact and agent full power and authority to do and
perform each and every act and thing requisite and necessary to be done in
and about the premises, as fully to all intents and purposes as the
undersigned might or could do in person, hereby ratifying and confirming all
said attorneys-in-fact and agent, or his substitute or substitutes, may
lawfully do or cause to be done by virtue thereof. The undersigned
acknowledges that the foregoing attorney-in-fact, in serving in such capacity
at the request of the undersigned, is not assuming any of the undersigned's
responsibilities to comply with Section 16 of the Securities Exchange Act of
1934.
This Power of Attorney shall remain in effect until such time as the
undersigned is no longer subject to the provisions of Section 16 of the
Securities Exchange Act or 1934 with respect to securities of the Issuer.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney
to be executed as of this 9th day of September 2019.
/s/ Nancy DiMattia