SEC 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
|Estimated average burden|
|hours per response:
||Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
1. Name and Address of Reporting Person*
|C/O DENTSPLY SIRONA INC|
|13320 BALLANTYNE CORPORATE PLACE|
2. Issuer Name and Ticker or Trading Symbol
DENTSPLY SIRONA Inc.
[ XRAY ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
||Officer (give title below)
||Other (specify below)
|Sr VP & Chief HR Officer|
3. Date of Earliest Transaction
4. If Amendment, Date of Original Filed
6. Individual or Joint/Group Filing (Check Applicable Line)
||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.
||2. Transaction Date
||2A. Deemed Execution Date, if any
||3. Transaction Code (Instr.
||4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr.
3 and 4)
||6. Ownership Form: Direct (D) or Indirect (I) (Instr.
||7. Nature of Indirect Beneficial Ownership (Instr.
||(A) or (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.
||2. Conversion or Exercise Price of Derivative Security
||3. Transaction Date
||3A. Deemed Execution Date, if any
||4. Transaction Code (Instr.
Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr.
3, 4 and 5)
||6. Date Exercisable and Expiration Date
||7. Title and Amount of Securities Underlying Derivative Security (Instr.
3 and 4)
||8. Price of Derivative Security (Instr.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
||10. Ownership Form: Direct (D) or Indirect (I) (Instr.
||11. Nature of Indirect Beneficial Ownership (Instr.
||Amount or Number of Shares
|Phantom Stock (Dentsply Supplemental Savings Plan) DSSP
|Explanation of Responses:|
||Dane Baumgardner, Attorney-In-Fact for Lisa Yankie
||** Signature of Reporting Person
|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,
|** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
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,
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
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-
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
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
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
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
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
IN WITNESS WHEREOF, the undersigned has
executed this Limited Power of Attorney as
of this 16th day of October 2019.
Signed and acknowledged: