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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 | |
Bevis Harold C C/O XERIUM TECHNOLOGIES, INC. 14101 CAPITAL BOULEVARD YOUNGSVILLE, NC 27596 |
X | President & CEO |
/s/ Kevin McDougall, by power of attorney | 08/27/2015 | |
**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) | Represents shares withheld in satisfaction of the $4.00 Employee Common Stock Option exercise price and the withholding tax liability in connection with the issuance of shares of common stock underlying the Employee Common Stock Option. |
(2) | Represents shares withheld in satisfaction of the withholding tax liability in connection with the issuance of shares of common stock underlying outstanding Restricted Stock Units. The Restricted Stock Units were granted to Mr. Bevis as sign-on awards when Mr. Bevis joined the Company. |
(3) | Includes 269,979 shares of common stock held by Mr. Bevis and 533,609 Restricted Stock Units that will be converted into shares of common stock, less tax withholdings, upon the satisfaction of all performance and time-based vesting conditions applicable to such Restricted Stock Units. |
Remarks: This Form 4 Amendment is being filed to correct tax withholding calculation errors in connection with the transactions identified above. The number of shares withheld in satisfaction of the $4.00 Employee Common Stock Option exercise price and the withholding tax liability in connection with the issuance of shares of common stock underlying the Employee Common Stock Option was corrected from 161,956 to 160,908. The number of shares withheld in satisfaction of the withholding tax liability in connection with the issuance of shares of common stock underlying outstanding Restricted Stock Units granted to Mr. Bevis when he joined the Company was corrected from 32,841 to 32,466. The number of shares of common stock noted as being held by Mr. Bevis in footnote 4 of the original Form 4 filing increased from 268,556 to 269,979 (as indicated in footnote 3 above). |