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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549ANNUAL STATEMENT 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 2270 (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 at End of Issuer's Fiscal Year (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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(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Margolis Robert J C/O DAVITA HEALTHCARE PARTNERS INC. 2000 16TH STREET DENVER, CO 80202 |
 X |  |  Co-Chairman of the Board |  |
/s/ Kim M. Rivera Attorney-in-Fact | 02/14/2013 | |
**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) | On November 1, 2012, the reporting person became entitled to receive 1,598,747 shares of common stock of DaVita HealthCare Partners Inc. pursuant to the terms and subject to the conditions of the Agreement and Plan of Merger, as amended, by and among, DaVita Inc. ("DaVita"), Seismic Acquisition LLC, a wholly owned subsidiary of DaVita ("Seismic"), HealthCare Partners Holdings, LLC ("HCP") and Robert D. Mosher as member representative, wherein Seismic merged with and into HCP, with HCP continuing as the surviving entity and as a wholly owned subsidiary of DaVita. DaVita was subsequently renamed DaVita HealthCare Partners Inc. The shares were deposited into the Robert and Lisa Margolis Family Trust, dated July 27, 2000 where the reporting person is trustee and beneficiary. |
(2) | A gift of 65,000 shares to the Margolis Family GST Exempt Trust, dated December 11, 2012. |
(3) | Margolis Family GST Exempt Trust, dated December 11, 2012. |