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
|
| 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*
| 13320 BALLANTYNE CORPORATE PLACE |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
05/22/2019
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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)
|
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| SVP, Chief Digital 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 |
|
Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
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 |
4,534.655
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D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 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)
|
6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Stock Option (Right to Buy) |
|
11/13/2028 |
Common Stock |
2,200 |
36.71 |
D |
|
| Stock Option (Right to Buy) |
|
11/13/2028 |
Common Stock |
11,600 |
36.71 |
D |
|
| Stock Option (Right to Buy) |
|
03/12/2029 |
Common Stock |
5,300 |
49.29 |
D |
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| Explanation of Responses: |
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Dane Baumgardner, Attorney-In-Fact for Chidambaram A. Chidambaram |
06/03/2019 |
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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. |
DENTSPLY SIRONA Inc.
Limited Power of Attorney for Section 16 Reporting
Obligations
Know all by these presents that the undersigned
hereby constitutes and appoints each of Keith
Ebling, and Dane Baumgardner, 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 perform any and all acts for and on
behalf of the undersigned which may be necessary or
desirable to complete and execute any such Forms 3,
4 or 5, complete and execute any amendments
thereto, and timely file such forms 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 attorneys-in-fact, in serving in such
capacity at the request and on the behalf of the
undersigned, 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 attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has executed
this Limited Power of Attorney as of this 22nd
day of May, 2019.
Signed and acknowledged:
/s/
Chidam Chidambaram
