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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 | |
BALK MARK D GOULSTON & STORRS, PC 400 ATLANTIC AVENUE BOSTON, MA 02110 |
Member of Schedule 13D group |
/s/ Mark D. Balk | 12/02/2004 | |
**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 (1) a gift of 350 shares by Amy Smith Berylson to J-J-E 1988 Trust udt dated November 1, 1988 fbo Jennifer L. Berylson, of which John G. Berylson and the reporting person are trustees; (2) a gift of 350 shares by Amy Smith Berylson to J-J-E 1988 Trust udt dated November 1, 1988 fbo James T. Berylson, of which John G. Berylson and the reporting person are trustees; and (3) a gift of 350 shares by Amy Smith Berylson to J-J-E 1988 Trust udt dated November 1, 1988 fbo Elizabeth S. Berylson, of which John G. Berylson and the reporting person are trustees. |
(2) | Represents (1) a gift of 350 shares by Debra Smith Knez to Debra and Brian Knez 1988 Childrens Trust udt dated December 1, 1988 fbo Jessica M. Knez, of which Brian J. Knez and the reporting person are trustees; and (2) a gift of 350 shares by Debra Smith Knez to Debra and Brian Knez 1988 Childrens Trust udt dated December 1, 1988 fbo Andrew P. Knez, of which Brian J. Knez and the reporting person are trustees. |
(3) | Represents (1) a gift of 350 shares by Robert A. Smith to Robert A. Smith and Dana Weiss 1994 Childrens Trust udt dated December 1, 1994 fbo Madeleine W. Smith, of which Dana A. Weiss and the reporting person are trustees; (2) a gift of 350 shares by Robert A. Smith to Robert A. Smith and Dana Weiss 1994 Childrens Trust udt dated December 1, 1994 fbo Ryan A. Smith, of which Dana A. Weiss and the reporting person are trustees; and (3) a gift of 350 shares by Robert A. Smith to Robert A. Smith and Dana Weiss 1994 Childrens Trust udt dated December 1, 1994 fbo Jackson A. Smith, of which Dana A. Weiss and the reporting person are trustees. |
(4) | Reflects the shares held indirectly by the reporting person as trustee of the following trusts: 18,078 shares owned indirectly as trustee of the Amy Smith Berylson 1998 Grantor Retained Annuity Trust f/b/o Jennifer L. Berylson; 18,078 shares owned indirectly as trustee of the Amy Smith Berylson 1998 Grantor Retained Annuity Trust f/b/o Elizabeth S. Berylson; 18,078 shares owned indirectly as trustee of the Amy Smith Berylson 1998 Grantor Retained Annuity Trust f/b/o James T. Berylson; |
(5) | 16,069 shares owned indirectly as trustee of the Robert A. Smith 1998 Grantor Retained Annuity Trust f/b/o Jackson A. Smith; 16,070 shares owned indirectly as trustee of the Robert A. Smith 1998 Grantor Retained Annuity Trust f/b/o Madeleine W. Smith; 16,069 shares owned indirectly as trustee of the Robert A. Smith 1998 Grantor Retained Annuity Trust f/b/o Ryan A. Smith; 23,803 shares owned indirectly as trustee of the Debra S. Knez 1998 Grantor Retained Annuity Trust f/b/o Jessica M. Knez; 23,802 shares owned indirectly as trustee of the Debra S. Knez 1998 Grantor Retained Annuity Trust f/b/o Andrew P. Knez; 5,376 shares owned indirectly as trustee of the J-J-E 1988 Trust f/b/o Jennifer L. Berylson; 5,376 shares owned indirectly as trustee of the J-J-E 1988 Trust f/b/o James T. Berylson; 5,376 shares owned indirectly by Mark D. Balk as trustee of the J-J-E 1988 Trust f/b/o Elizabeth S. Berylson; |
(6) | 6,199 shares owned indirectly as trustee of the Debra and Brian Knez 1988 Childrens Trust f/b/o Jessica M. Knez; 6,199 shares owned indirectly as trustee of the Debra and Brian Knez 1988 Childrens Trust f/b/o Andrew P. Knez; 4,741 shares owned indirectly as trustee of the Robert Smith and Dana Weiss 1994 Childrens Trust f/b/o Madeleine W. Smith; 4,741 shares owned indirectly as trustee of the Robert Smith and Dana Weiss 1994 Childrens Trust f/b/o Ryan A. Smith; 4,741 shares owned indirectly as trustee of the Robert Smith and Dana Weiss 1994 Childrens Trust f/b/o Jackson A. Smith; |
(7) | 48,208 shares owned indirectly as trustee of the Amy Smith Berylson 1978 Insurance Trust u/d/t dated September 5, 1978; 48,208 shares owned indirectly as trustee of the Robert Smith Insurance Trust u/d/t dated September 5, 1978; 48,208 shares owned as trustee of the Debra Smith Knez Insurance Trust u/d/t dated September 5, 1978; 96,416 shares owned indirectly as trustee of the Nancy Lurie Marks 1976 Trust f/b/o Cathy Lurie u/d/t dated December 16, 1976; 96,416 shares owned indirectly as trustee of the Nancy Lurie Marks 1976 Trust f/b/o Peter Lurie u/d/t dated December 16, 1976; 28,997 shares owned indirectly as trustee of the Susan F. Smith Grantor Retained Annuity Trust 7 Years u/d/t dated August 10, 1994 f/b/o Amy Smith Berylson; |
(8) | 28,997 shares owned indirectly as trustee of the Susan F. Smith Grantor Retained Annuity Trust 7 Years u/d/t dated August 10, 1994 f/b/o Robert A. Smith; 28,997 shares owned indirectly as trustee of the Susan F. Smith Grantor Retained Annuity Trust 7 Years u/d/t dated August 10, 1994 f/b/o Debra Smith Knez; 10,388 shares owned indirectly as trustee of the ADR Charitable Foundation and Trust u/d/t dated 11/1/68. The reporting person disclaims beneficial ownership of all of these shares and this report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. |