SEC FORM 3/A SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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: 3235-0104
Estimated average burden
hours per response: 0.5
1. Name and Address of Reporting Person*
LAWRENCE JEFFREY D

(Last) (First) (Middle)
30 FRANK LLOYD WRIGHT DR

(Street)
ANN ARBOR MI 48105

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
08/28/2015
3. Issuer Name and Ticker or Trading Symbol
DOMINOS PIZZA INC [ DPZ ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Chief Financial Officer
5. If Amendment, Date of Original Filed (Month/Day/Year)
09/01/2015
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 Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock, $0.01 par value 15,694.478(1)(2)(3)(4)(5)(6)(7) D
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Explanation of Responses:
1. This amendment is being filed to correct a clerical error in the original Form 3.
2. Includes 823.345 shares acquired under the Domino's Employee Stock Payroll Deduction Plan.
3. Includes 890 shares of common stock representing two-fourths of an original grant of performance-based restricted stock that shall vest one-half on each of July 17, 2016 and July 17, 2017 if applicable performance conditions are achieved.
4. Includes 1,060 shares of common stock representing two-fourths of an original grant of performance-based restricted stock that shall vest one-half on each of February 27, 2016 and February 27, 2017 if applicable performance conditions are achieved.
5. Includes 1,133 shares of common stock representing three-fourths of an original grant of performance-based restricted stock that shall vest one-third on each of July 16, 2016, July 16, 2017 and July 16, 2018 if applicable performance conditions are achieved.
6. Includes 960 shares of common stock representing a grant of performance-based restricted stock that shall vest one-fourth on each of July 15, 2016, July 15, 2017, July 15, 2018 and July 15, 2019 if applicable performance conditions are achieved.
7. Includes 2,110 shares of common stock representing a grant of performance-based restricted stock that shall vest one-fourth on each of July 15, 2016, July 15, 2017, July 15, 2018 and July 15, 2019 if applicable performance conditions are achieved.
Remarks:
/s/ Adam J. Gacek, attorney-in-fact 09/15/2015
** 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 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).
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.