UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF 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. | SEC 1473 (7-02) | ||
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. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Class B Common Stock | Â (1) | Â (1) | Class A Common Stock | 50,000 | $ 0 | D | Â |
Class B Common Stock | Â (1) | Â (1) | Class A Common Stock | 100,000 | $ 0 | I | See Footnote (2) |
Class B Common Stock | Â (1) | Â (1) | Class A Common Stock | 100,000 | $ 0 | I | See Footnote (3) |
Class B Common Stock | Â (1) | Â (1) | Class A Common Stock | 49,135,353 | $ 0 | I | See Footnote (4) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
BURD STEVEN A C/O BLACKHAWK NETWORK HOLDINGS, INC. 6220 STONERIDGE MALL ROAD PLEASANTON, CA 94588 |
 X |  |  |  |
/s/ Marcia Peterson, as Attorney-in-Fact for Steven A. Burd | 04/18/2013 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 5(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) | Each share of Class B Common Stock is convertible at any time at the option of the Reporting Person into one share of Class A Common Stock and has no expiration date. Class B Common Stock will convert automatically into Class A Common Stock upon the occurrence of a Conversion Event, as such term is defined in section 3(a)(ii) of the Issuer's Amended and Restated Certificate of Incorporation. |
(2) | The shares are held by The Christopher Dell Burd 1995 Trust. |
(3) | The shares are held by The Jason Carl Burd 1995 Trust. |
(4) | The shares are held by Safeway Inc ("Safeway"). The Reporting Person is the Chief Executive Officer and Chairman of the board of directors of Safeway and may be deemed to be the beneficial owner of the shares of Class B Common Stock held by Safeway. The Reporting Person disclaims beneficial ownership of the Class B Common Stock held by Safeway, except to the extent of his pecuniary interest therein. |