SEC FORM
4
SEC Form 4
| FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
|
| OMB APPROVAL |
| OMB Number: |
3235-0287 |
| Estimated average burden |
| hours per response: |
0.5 |
|
|
 |
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b). |
1. Name and Address of Reporting Person*
| C/O DOMINO'S PIZZA, INC. |
| 30 FRANK LLOYD WRIGHT DRIVE |
(Street)
|
2. Issuer Name and Ticker or Trading Symbol
DOMINOS PIZZA INC
[ DPZ ]
|
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| Chief Executive Officer |
|
3. Date of Earliest Transaction
(Month/Day/Year)
02/15/2005
|
4. If Amendment, Date of Original Filed
(Month/Day/Year)
|
6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting Person |
|
| Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
|---|
| 1. Title of Security (Instr.
3)
|
2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
|
4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
|
5.
Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr.
3 and 4)
|
6. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
|
7. Nature of Indirect Beneficial Ownership (Instr.
4)
|
| Code |
V |
Amount |
(A) or (D) |
Price |
| Common Stock, $.01 par value |
02/15/2005 |
|
M |
|
17,500 |
A |
$0.75
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
200 |
D |
$16.81
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
500 |
D |
$16.82
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
100 |
D |
$16.83
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
1,000 |
D |
$16.84
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
2,200 |
D |
$16.85
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
200 |
D |
$16.87
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
300 |
D |
$16.88
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
800 |
D |
$16.89
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
100 |
D |
$16.91
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
5,200 |
D |
$17
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
6,400 |
D |
$17.1
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
200 |
D |
$17.12
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
200 |
D |
$16.86
|
138,078 |
D |
|
| Common Stock, $.01 par value |
02/15/2005 |
|
S |
|
100 |
D |
$16.8
|
138,078 |
D |
|
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 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 Securities Underlying Derivative Security (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: Direct (D) or Indirect (I) (Instr.
4)
|
11. Nature of Indirect Beneficial Ownership (Instr.
4)
|
| Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Options to purchase Common Stock |
$0.75
|
02/15/2005 |
|
M |
|
|
17,500 |
03/31/2004 |
03/31/2009 |
Common Stock, $.01 par value |
17,500 |
$0
|
973,344 |
D |
|
| Explanation of Responses: |
|
/s/ Adam J. Gacek, Attorney in Fact |
02/15/2005 |
|
** Signature of Reporting Person |
Date |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
| * 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). |
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
| 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 Number. |
rrd58325_66150.html
POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby constitutes and appoints each of Adam Gacek
and Meghan Vesey, signing singly, the undersigned's true and lawful attorney-in-fact to:
(1)execute for and on behalf of the undersigned, in the undersigned's capacity as an officer and/or
director of Domino's Pizza, Inc. (the "Company"), Forms 3, 4, and 5 in accordance with Section 16(a)
of the Securities Exchange Act of 1934 and the rules thereunder;
(2)do and perform any and all acts for and on behalf of the undersigned which may be necessary or
desirable to complete and execute any such Form 3, 4, or 5, complete and execute any amendment or
amendments thereto, and timely file such form with the United States Securities and Exchange Commission
and any stock exchange or similar authority; and
(3)take any other action of any type whatsoever in connection with the foregoing which, in the opinion
of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the
undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the
undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and
conditions as such attorney-in-fact may approve in such attorney-in-fact's discretion.
The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform
any and every act and thing whatsoever requisite, necessary, or proper to be done in the exercise of
any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned
might or could do if personally present, with full power of substitution or revocation, hereby ratifying
and confirming all that such attorney-in-fact, or such attorney-in-fact's substitute or substitutes,
shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers
herein granted.
The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the
request of the undersigned, are not assuming, nor is the Company assuming, any of the undersigned's
responsibilities to comply with Section 16 of the Securities Exchange Act of 1934.
This Power of Attorney shall remain in full force and effect until the undersigned is no longer required
to file Forms 3, 4, and 5 with respect to the undersigned's holdings of and transactions in securities
issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the
foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 8th day
of February, 2005.
Signature /s/ David A. Brandon
Name David A. Brandon
