Form 3 Genesis Healthcare, Inc. For: Jan 01 Filed by: Bach Paul David
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January 9, 2017 12:31 PM EST
| 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 |
| Expires: |
December 31, 2014 |
| Estimated average burden |
| hours per response: |
0.5 |
|
|
1. Name and Address of Reporting Person
*
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year)
01/01/2017
|
3. Issuer Name
and
Ticker or Trading Symbol
Genesis Healthcare, Inc.
[
GEN
]
|
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| COO |
|
5. If Amendment, Date of Original Filed
(Month/Day/Year)
|
6. Individual or Joint/Group Filing (Check
Applicable Line)
| X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting
Person |
|
| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
|
3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
|
4. Nature of Indirect Beneficial Ownership (Instr.
5)
|
|
Class A Common Stock
|
463,390
(1)
|
D
|
|
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 1. Title of Derivative Security (Instr.
4)
|
2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
|
4. Conversion or Exercise Price of Derivative Security
|
5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
|
6. Nature of Indirect Beneficial Ownership (Instr.
5)
|
| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
|
Class A Common Units of FC-GEN Operations Investment, LLC
|
|
|
Class A Common Stock
|
372,996
|
(2)
|
D
|
|
|
Class C Common Stock
|
|
|
Class A Common Stock
|
64
|
(3)
|
D
|
|
| Explanation of Responses: |
|
|
|
|
Michael Berg, Attorney-in-Fact For: Paul David Bach |
01/09/2017 |
|
** 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
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). |
| 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. |
POWER OF ATTORNEY
KNOW ALL BY THESE PRESENTS, that the undersigned hereby constitutes and
appoints Michael Sherman, Michael Berg and Thomas DiVittorio, each of
Genesis Healthcare, Inc., a corporation firm having its principal office
located at 101 East State Street Kennett Square, PA 19348, as lawful
attorneys-in-fact, solely for the following purposes, and hereby confers
upon such attorneys-in-fact full power and authority to perform each and
all of the following acts in the name of and on behalf of the undersigned.
(1) To prepare, execute and file with the United States Securities
and Exchange Commission those filings required pursuant to Section 16 of
the Securities Exchange Act of 1934 on behalf of the undersigned and to
receive any notice given to the undersigned in connection therewith; and
(2) To take any other action of any type whatsoever in connection
with the foregoing which, in the opinion of such attorneys-in-fact, may
be of benefit to, in the best interest of, or legally required by, the
undersigned, it being understood that the documents executed by such
attorneys-in-fact on behalf of the undersigned pursuant to this
Power of Attorney shall be in such form and shall contain such terms
and conditions as such attorneys-in-fact may approve in such
attorneys-in-fact's discretion.
The undersigned hereby grants to the attorneys-in-fact full power and
authority to do and perform any and every act and thing whatsoever
requisite, 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 attorneys-in-fact, or such attorneys-in-fact's
substitute or substitutes, shall lawfully do or cause to be done by
virtue of this Power of Attorney and the rights and powers herein granted.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney
to be executed as of this 19th day of December, 2016.
By:/s/Paul David Bach
Name:Paul David Bach
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