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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 | |
Berylson John G C/O MARK D. BALK, GOULSTON & STORRS, PC 400 ATLANTIC AVENUE BOSTON, MA 02110 |
Member of Schedule 13D group |
/s/ Mark D. Balk, Attorney-in-Fact | 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 to J-J-E 1988 Trust udt dated November 1, 1988 fbo Jennifer L. Berylson, of which the reporting person and Mark D. Balk are trustees; (2) a gift of 350 shares to J-J-E 1988 Trust udt dated November 1, 1988 fbo James T. Berylson, of which the reporting person and Mark D. Balk are trustees; and (3) a gift of 350 shares to J-J-E 1988 Trust udt dated November 1, 1988 fbo Elizabeth S. Berylson, of which the reporting person and Mark D. Balk are trustees. |
(2) | Reflects the shares owned directly or indirectly by the following persons or entities and indirectly by the reporting person: 189,918 shares owned directly by Amy Smith Berylson, the wife of the reporting person; 28,997 shares owned indirectly by Amy Smith Berylson 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; 5,376 shares owned indirectly by the reporting person as trustee of the J-J-E 1988 Trust udt dated November 1, 1988 fbo Jennifer Berylson; 5,376 shares owned indirectly by the reporting person as trustee of the J-J-E 1988 Trust udt dated November 1, 1988 fbo James Berylson; 5,376 shares owned indirectly by the reporting person as trustee of the J-J-E 1988 Trust udt dated November 1, 1988 fbo Elizabeth Berylson; |
(3) | 18,078 shares owned indirectly by the reporting person as trustee of the Amy Smith Berylson 1998 Grantor Retained Annuity Trust fbo Jennifer L. Berylson; 18,078 shares owned indirectly by the reporting person as trustee of the Amy Smith Berylson 1998 Grantor Retained Annuity Trust fbo Elizabeth S. Berylson; 18,078 shares owned indirectly by the reporting person as trustee of the Amy Smith Berylson 1998 Grantor Retained Annuity Trust fbo James T. Berylson; 59,529 shares owned indirectly by the reporting person and Amy Smith Berylson as trustees of the Amy Smith Berylson Grantor Retained Annuity Trust; |
(4) | 48,208 shares owned indirectly by Amy Smith Berylson as trustee of the Amy Smith Berylson Insurance Trust; 6,685 shares owned directly by Jennifer L. Berylson, the daughter of the reporting person; 6,686 shares owned indirectly by John G. Berylson and Amy Smith Berylson as guardians for James Berylson, the son of the reporting person; and 6,686 shares owned indirectly by John G. Berylson and Amy Smith Berylson as guardians for Elizabeth Berylson, the daughter of the reporting person. The reporting person disclaims beneficial ownership of all 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. |