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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Burt Carol 6200 S. SYRACUSE WAY STE 200 GREENWOOD VILLAGE, CO 80111 |
X |
/s/ Craig A. Wilson, Attorney-in-Fact for Carol J. Burt | 12/01/2016 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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). |
(1) | Disposition pursuant to the terms of the Agreement and Plan of Merger, dated as of June 15, 2016, by and among Envision Healthcare Holdings, Inc., New Amethyst Corp. and AmSurg Corp. (the "Merger Agreement"), exempt under Rule 16b-3. |
(2) | Pursuant to the terms of the Merger Agreement, at the Merger 2 Effective Time, each share of common stock held by the reporting person immediately prior to the Merger 2 Effective Time (as defined in the Merger Agreement) was assumed by New Amethyst and converted into a New Amethyst share of common stock having the same terms and conditions, taking into account any changes thereto by reason of the Mergers (as defined in the Merger Agreement). |
(3) | Represents restricted stock units granted as director fees. The restricted stock units vest on the earlier of (i) the one year anniversary of the grant date or (ii) the date of the Company's next annual shareholders meeting, in each case subject to Ms. Burt's continued service on the Company's board of directors, and will be settled upon vesting. |
(4) | Pursuant to the terms of the Merger Agreement, at the Merger 2 Effective Time, each restricted stock unit held by the reporting person immediately prior to the Merger 2 Effective Time (as defined in the Merger Agreement) was assumed by New Amethyst and converted into a New Amethyst restricted stock unit having the same terms and conditions, taking into account any changes thereto by reason of the Mergers (as defined in the Merger Agreement). |
(5) | These restricted stock units are held by the Carol Burt Hilliard Trust dated February 26, 2009. |