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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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 control number. | SEC 1474 (9-02) |
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 Underlying Securities (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 of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Director Stock Opt (right to buy) | $ 3.17 | 10/20/2004 | A(4) | 5,000 | 10/20/2004 | 01/15/2012 | Common Stock | 5,000 | (4) | 5,000 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
DAVIS T WAYNE 1910 SAN MARCO BLVD. JACKSONVILLE, FL 32207 |
X |
H. J. Skelton, Attorney-In-Fact for T. Wayne Davis | 10/22/2004 | |
**Signature of Reporting Person | Date |
* | 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). |
(1) | 947 shares of Winn-Dixie common stock were awarded under the stock plan for directors. |
(2) | As to a portion of the shares reported on this line representing the beneficial interest of T. Wayne Davis' wife and children, the filing of this statement shall not be construed as an admission that T. Wayne Davis is, for the purpose of Section 16 of the Securities Exchange Act of 1934, the beneficial owner of such shares of stock and T. Wayne Davis disclaims beneficial ownership of such shares of stock. |
(3) | Represents shares held by the Profit Sharing Trust for TWD Family - WD Charities, Inc. of which T. Wayne Davis is Trustee and a 65.37% participant. |
(4) | T. Wayne Davis was granted the option to purchase 5,000 shares of Winn-Dixie common stock at $3.17 per share under the stock plan for directors. |