Sec Form 4 Filing - BALSON ANDREW @ DOMINOS PIZZA INC - 2020-01-24

Insider filing report for Changes in Beneficial Ownership
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FORM 4
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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, 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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1. Name and Address of Reporting Person
BALSON ANDREW
2. Issuer Name and Ticker or Trading Symbol
DOMINOS PIZZA INC [ DPZ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X __ Director _____ 10% Owner
_____ Officer (give title below) _____ Other (specify below)
(Last) (First) (Middle)
C/O DOMINO'S PIZZA, 30 FRANK LLOYD WRIGHT DRIVE
3. Date of Earliest Transaction (MM/DD/YY)
01/24/2020
(Street)
ANN ARBOR, MI48105
4. If Amendment, Date Original Filed (MM/DD/YY)
6. Individual or Joint/Group Filing (Check Applicable Line)
__ X __ Form filed by One Reporting Person
_____ Form filed by More than One Reporting Person
(City) (State) (Zip)
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1.Title of Security
(Instr. 3)
2. Transaction Date (MM/DD/YY) 2A. Deemed Execution Date, if any (MM/DD/YY) 3. Transaction Code
(Instr. 8)
4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
7. Nature of Indirect Beneficial Ownership
(Instr. 4)
Code V Amount (A) or (D) Price
Common Stock, $0.01 par value 01/24/2020 M 6,000 ( 1 ) A $ 12.43 57,283 D
Common Stock, $0.01 par value 27,310 I Andrew B. Balson 2004 Irrevocable Family Trust
Common Stock, $0.01 par value 8,870 I Andrew B. Balson 2011 Irrevocable Family Trust
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
( e.g. , puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security
(Instr. 3)
2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (MM/DD/YY) 3A. Deemed Execution Date, if any (MM/DD/YY) 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
(MM/DD/YY)
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)
Code V (A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Option to Purchase Common Stock $ 12.43 01/24/2020 M 6,000 02/25/2011 02/25/2020 Common Stock, $0.01 par value 6,000 $ 0 0 D
Reporting Owners
Reporting Owner Name / Address Relationships
Director 10% Owner Officer Other
BALSON ANDREW
C/O DOMINO'S PIZZA
30 FRANK LLOYD WRIGHT DRIVE
ANN ARBOR, MI48105
X
Signatures
/s/ Kevin S. Morris, attorney-in-fact 01/28/2020
Signature of Reporting Person Date
Explanation of Responses:
( 1 )Represents the acquisition of common stock resulting from the exercise and hold of derivative securities reported in Table II.

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* If the form is filed by more than one reporting person, see Instruction 4(b)(v).
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