SEC FORM
3
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
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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| 221 WEST PHILADELPHIA STREET STE 60 W |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
04/07/2016
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3. Issuer Name and Ticker or Trading Symbol
DENTSPLY SIRONA Inc.
[ XRAY ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| Sr VP & Chief HR Officer |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
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| 1. Title of Security (Instr.
4)
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2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Common Stock |
13,530 |
D |
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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 Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Supplemental Executive Retirement Plan (SERP) |
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Common Stock |
6,637 |
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D |
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| RSU (Restricted Stock Unit) |
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Common Stock |
10,749.958 |
0
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D |
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| PRSU (Performance Measured Restricted Stock Unit) |
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Common Stock |
5,202.8 |
0
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D |
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| Stock Option |
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04/14/2019 |
Common Stock |
17,650 |
26.72 |
D |
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| Stock Option |
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12/08/2019 |
Common Stock |
23,200 |
33.86 |
D |
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| Stock Option |
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02/11/2021 |
Common Stock |
21,900 |
36.62 |
D |
|
| Stock Option |
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02/21/2022 |
Common Stock |
18,300 |
38.74 |
D |
|
| Stock Option |
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02/25/2023 |
Common Stock |
13,800 |
40.86 |
D |
|
| Stock Option |
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02/24/2024 |
Common Stock |
15,000 |
45.11 |
D |
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| Stock Option |
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02/23/2025 |
Common Stock |
14,800 |
52 |
D |
|
| Stock Option |
|
02/17/2026 |
Common Stock |
12,100 |
55.91 |
D |
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| Explanation of Responses: |
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| Remarks: |
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Michael Friedlander, Attorney-In-Fact for Maureen J. MacInnis |
04/18/2016 |
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** 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. |
LIMITED POWER OF ATTORNEY FOR SECTION 16 REPORTING OBLIGATIONS
Know all by these presents, that the undersigned hereby
constitutes and appoints each of Jonathan I. Friedman, and
Michael Friedlander, or either of them acting singly and with
full power of substitution, 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 or director or both of
DENTSPLY SIRONA Inc. (the "Company"), Forms 3, 4 and 5 (and any
amendments thereto) in accordance with Section 16(a) of the
Securities Exchange Act of 1934, as amended (the "Exchange Act"),
and the rules thereunder;
2. To 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
amendments thereto, and timely file such form with the U.S.
Securities and Exchange Commission (the "SEC") [and any
securities exchange or similar authority], including without
limitation the filing of a Form ID or any other documents
necessary or appropriate to enable the undersigned to file the
Forms 3, 4 and 5 electronically with the SEC;
3. Seek or obtain, as the undersigned's representative and
on the undersigned's behalf, information on transactions in the
Company's securities from any third party, including brokers,
employee benefit plan administrators and trustees, and the
undersigned hereby authorizes any such person to release any such
information to each of the undersigned's attorneys-in-fact
appointed by this Limited Power of Attorney and approves and
ratifies any such release of information;
4. Take any other action 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 or for, the
undersigned, it being understood that the documents executed by
such attorney-in-fact on behalf of the undersigned pursuant to
this Limited Power of Attorney shall be in such form and shall
contain such information and disclosure 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 required, 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 Limited Power of Attorney and the rights and powers herein
granted.
The undersigned acknowledges that the foregoing
attorney(s)-in-fact, in serving in such capacity at the request
and on the behalf of the undersigned, is(are) not assuming, nor
is the Company assuming, any of the undersigned's
responsibilities to comply with, or any liability for the failure
to comply with, any provision of Section 16 of the Exchange Act.
This Limited Power of Attorney shall remain in full
force and effect until the undersigned is no longer required to
file Forms 3, 4 or 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 attorney(s)-in-fact.
IN WITNESS WHEREOF, the undersigned has executed this Limited
Power of Attorney as of this 7th day of April, 2016.
Signed and acknowledged:
/s/
Maureen J. MacInnis
)-in-fact.
IN WITNESS WHEREOF, the undersigned has executed this Limited
Power of Attorney as of this 7th day of April, 2016.
Signed and acknowledged:
/s/
