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) 08/01/2016
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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)
X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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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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Common Stock |
2,218 |
D |
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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: |
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/s/ Amanda Lorentz as Attorney-in-Fact for Philip B. Livingston pursuant to Power of Attorney filed herewith. |
08/04/2016 |
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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 Kirk Gedelmann,
John R. Houston, Elizabeth M. Dunshee and Amanda Lorentz, 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
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 3rd day of August 2016.
/s/ Philip B. Livingston