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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 | ||||||||
Exchangeable units (3) | (3) | 11/15/2017 | J(4) | 1,500,000 | (3) | (3) | Common Shares | 1,500,000 | $ 0 | 1,500,000 | I | See Footnote (1) | |||
Option (right to buy) | $ 3.54 | (5) | 02/02/2021 | Common Shares | 106,050 | 106,050 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Sicupira Carlos Alberto 226 WYECROFT ROAD OAKVILLE, A6 L6K 3X7 |
X |
/s/ Lisa Giles-Klein as attorney-in-fact for Carlos Alberto Sicupira | 11/17/2017 | |
**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) | Represents an indirect interest held by CHL Investment Fund Ltd. The Reporting Person is an indirect beneficial owner of equity interests in CHL Investment Fund Ltd. The Reporting Person disclaims beneficial ownership of any shares in which he does not have a pecuniary interest. |
(2) | Reflects a transfer of 779,090 shares previously reported as indirectly beneficially owned through Lobstertail Corporation. The transfer of shares was exempt from reporting pursuant to Rule 16a-13 under the Securities and Exchange Act of 1934, as amended. |
(3) | Each Restaurant Brands International Limited Partnership exchangeable unit is convertible, at the Reporting Person's election, into common shares of Restaurant Brands International Inc. or a cash amount equal to a prescribed cash amount determined by reference to the weighted average trading price of Restaurant Brands International Inc.'s common shares on the New York Stock Exchange for the 20 consecutive trading days ending on the last business day prior to the exchange date, at the sole discretion of the general partner of Restaurant Brands International Limited Partnership (subject to the consent of the Restaurant Brands International Inc. conflicts committee, in certain circumstances). This conversion right has no expiration date. |
(4) | Represents a distribution from 3G Restaurant Brands Holdings LP, of which CHL Investment Fund Ltd. is a limited partner. |
(5) | These options are immediately exercisable. |