Statement of Changes in Beneficial Ownership (4)
August 29 2018 - 5:44PM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
Musallam Ramzi M
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2. Issuer Name
and
Ticker or Trading Symbol
Cotiviti Holdings, Inc.
[
COTV
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
__
X
__ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
C/O VERITAS CAPITAL FUND MANAGEMENT, LLC, 9 WEST 57TH STREET, 29TH FLOOR
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3. Date of Earliest Transaction
(MM/DD/YYYY)
8/27/2018
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(Street)
NEW YORK, NY 10019
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
___ Form filed by One Reporting Person
_
X
_ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock
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8/27/2018
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J
(1)
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94027266
(1)
(2)
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A
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$44.75
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100
(2)
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I
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See footnote
(2)
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Explanation of Responses:
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(1)
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On August 27, 2018, pursuant to the Agreement and Plan of Merger, dated as of June 19, 2018, by and among the Issuer, Verscend Technologies, Inc., a Delaware corporation ("Verscend"), and Rey Merger Sub, Inc., a Delaware corporation and a wholly owned subsidiary of Verscend ("Merger Sub"), Merger Sub merged (the "Merger") with and into the Issuer, with the Issuer surviving as a wholly owned subsidiary of Verscend. As a result of the effectiveness of the Merger, the common stock, par value $0.001 per share of Cotiviti (the "Shares"), ceased to be traded on the New York Stock Exchange, the registration of the Shares will be terminated pursuant to Section 12(g) of the Exchange Act and Cotiviti will no longer be required to file periodic reports with the SEC.
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(2)
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Each of the Reporting Persons disclaims any beneficial ownership of these Securities, except to the extent of its pecuniary interests therein.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Musallam Ramzi M
C/O VERITAS CAPITAL FUND MANAGEMENT, LLC
9 WEST 57TH STREET, 29TH FLOOR
NEW YORK, NY 10019
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X
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Verisk Health, Inc. / DE
C/O VERSCEND TECHNOLOGIES, INC.
201 JONES ROAD, 4TH FLOOR
WALTHAM, MA 02451
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See Remarks
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Verscend Holding Corp.
C/O VERSCEND TECHNOLOGIES, INC.
201 JONES ROAD, 4TH FLOOR
WALTHAM, MA 02451
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See Remarks
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Verscend Holding II Corp.
C/O VERSCEND TECHNOLOGIES, INC.
201 JONES ROAD, 4TH FLOOR
WALTHAM, MA 02451
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See Remarks
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Verscend Intermediate Holding Corp.
C/O VERSCEND TECHNOLOGIES, INC.
201 JONES ROAD, 4TH FLOOR
WALTHAM, MA 02451
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See Remarks
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Verscend Holdings L.L.C.
C/O VERITAS CAPITAL FUND MANAGEMENT, LLC
9 WEST 57TH STREET, 29TH FLOOR
NEW YORK, NY 10019
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See Remarks
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Veritas Capital Fund V, L.P.
C/O VERITAS CAPITAL FUND MANAGEMENT, LLC
9 WEST 57TH STREET, 29TH FLOOR
NEW YORK, NY 10019
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See Remarks
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Veritas Capital Partners V, L.L.C.
C/O VERITAS CAPITAL FUND MANAGEMENT, LLC
9 WEST 57TH STREET, 29TH FLOOR
NEW YORK, NY 10019
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See Remarks
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Signatures
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/s/ Ramzi M. Musallam
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8/29/2018
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**
Signature of Reporting Person
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Date
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/s/ Emad Rizk, Chief Executive Officer and President of Verscend Technologies, Inc.
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8/29/2018
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**
Signature of Reporting Person
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Date
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/s/ Emad Rizk, Chief Executive Officer and President of Verscend Holding Corp.
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8/29/2018
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**
Signature of Reporting Person
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Date
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/s/ Emad Rizk, Chief Executive Officer and President of Verscend Holding II Corp.
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8/29/2018
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**
Signature of Reporting Person
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Date
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/s/ Emad Rizk, Chief Executive Officer and President of Verscend Intermediate Holding Corp.
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8/29/2018
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**
Signature of Reporting Person
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Date
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/s/ Ramzi M. Musallam, Chief Executive Officer and Managing Partner of Veritas Capital Fund Management, L.L.C., the non-member manager of Verscend Holdings LLC
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8/29/2018
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**
Signature of Reporting Person
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Date
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/s/ Ramzi M. Musallam, Managing Partner of Veritas Capital Partners V, L.L.C., the general partner of The Veritas Capital Fund V, L.P.
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8/29/2018
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**
Signature of Reporting Person
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Date
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/s/ Ramzi M. Musallam, Managing Partner of Veritas Capital Partners V, L.L.C.
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8/29/2018
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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