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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549ANNUAL STATEMENT 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 2270 (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 at End of Issuer's Fiscal Year (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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(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Brink Diane D C/O BELDEN INC. 1 N. BRENTWOOD BLVD., 15TH FLOOR SAINT LOUIS, MO 63105 |
 X |  |  |  |
/s/ Brian E. Anderson, attorney-in-fact for Diane D. Brink | 01/25/2018 | |
**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) | The Reporting Person was elected to the Belden Inc. (the "Company") Board of Directors on December 6, 2017. Due to an administrative oversight by the Company, the required Form 3 was not filed in a timely manner. At the time of her appointment, the Reporting Person did not own any Company securities. |
(2) | In connection with her appointment to the Company's Board of Directors on December 6, 2017, the Reporting Person was granted 2,500 restricted stock units ("RSUs"). The RSUs will vest in equal portions on the first three anniversaries of the grant date, but are subject to accelerated vesting under certain circumstances, including death, disability and retirement. Due to an administrative oversight by the Company, the required Form 4 was not filed in a timely manner. |