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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 | |
COMMUNITY HEALTH SYSTEMS INC 4000 MERIDIAN BOULEVARD FRANKLIN, TN 37067 |
X |
/s/ Jay H. Knight, Attorney in Fact for Rachel A. Seifert, EVP and Corporate Secretary | 04/29/2016 | |
**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) | In connection with the spin-off of Quorum Health Corporation ("QHC") by Community Health Systems, Inc. ("CHS"), on April 29, 2016, CHS distributed 100% of the outstanding shares of common stock, $0.0001 par value, of QHC owned by CHS to the holders of CHS common stock as of the close of business on April 22, 2016, the record date for the distribution. |
(2) | In connection with the spin-off of QHC by CHS, on April 29, 2016, QHC effected a forward stock split, which resulted in the reporting person's ownership of 1,000 shares being converted into 28,438,547 shares. |
(3) | These shares were owned indirectly through CHS-QHC Bridge Company, LLC, a Delaware limited liability company, which is a wholly-owned subsidiary of CHS/Community Health Systems, Inc., a Delaware corporation, which is a wholly-owned subsidiary of CHS. |